Skip to main content
ReadyRule homepageReadyRule

Inspection visit

Health inspection

COMPLETE CARE AT HARSTON HALL LLCCMS #39579123 citations on this visit
23 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 23 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy and interviews with residents, it was determined that the facility failed to promote and maintain dignity and respect for two of 24 residents reviewed (Resident R100 and R40). Findings include: Review of facility policy Promoting/ Maintaining Resident Dignity, implemented on September 1, 2024, revealed it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Under Compliance guidelines, all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Review of Resident R100's clinical record revealed that Resident R100 was admitted to the facility on [DATE] with diagnoses of, but not limited to, Parkinson's Disease (movement disorder that affects the nervous system and worsens over time) and Type 2 Diabetes (failure of the body to produce insulin). Review of Resident R100's Minimum Data Set (MDS- assessment of resident care needs) revealed that Resident R11 had a BIMS (Brief interview for mental status) of 13, which indicated that the resident was cognitively intact. Interview with Resident R100 on April 22, 2025 at 11:32 am revealed resident felt staff was constantly disrespectful, refused to give their names or showed their identification upon request. The resident felt staff was mean to him and gave him a hard time when he asked for assistance. Review of Resident R40 's clinical record revealed that Resident R40 was admitted to the facility on [DATE] with diagnosis of, but not limited to, left femur fracture, Type 2 diabetes, heart disease. Review of Resident R40 's MDS revealed that the resident has a BIMS of 12, indicating resident was cognitively intact. Interview with Resident R40 on April 22, 2025 at 11:40am revealed resident felt that staff was disrespectful. Staff woke resident up in the middle of the night without explanation, did not answer questions when asked, talked down to the resident. Resident stated that there was no way to identify staff, they did not wear name tags, if you ask the name of a staff member, they become very defensive Page 1 of 34 395791 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0550 Level of Harm - Minimal harm or potential for actual harm and hostile and refuse to give their name. Staff told resident If you want the name you have to talk to administration. Observation of staff on April 23, 2025 at 09:45 am, revealed Licensed nurse, Employee E10, identification badge not clearly displayed (badge hidden behind other cards). Residents Affected - Few Observation of Staff on April 24, 2025 at 09:23 am revealed Licnesed nurse, Employee E9 not wearing identification badge. Observation of Staff on April 24, 2025 09:26 am revealed Licensed nurse, Employee E5, identification badge not clearly displayed (Badge on lanyard behind multiple other cards). 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (j ) Resident rights 395791 Page 2 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy and observations, it was determined that the facility failed to provide a sanitary, clean, comfortable, homelike environment for one out the two units observed. (Third floor nursing unit). Findings include: A review of the policy titled Home Environment revised on July 1, 2024, under the Policy Guidelines #3 Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. On April 22, 2025, at 12:51 p.m. observation of room [ROOM NUMBER]B had a significant urine smell. On April 24, 2025, an observation of room [ROOM NUMBER]A revealed that Resident R10, who had passed away on April 22, 2025, had not had her room cleaned or cleared. Her personal belongings remained in place, including her reclining chair, which, according to Licensed Nurse Employee E6, was broken and being used to store random items. The items included ankle protectors and uncovered pillows. Both bedside dressers were covered with a noticeable layer of dust. Resident R10 had two dressers, and behind one of them, a broken television was stored alongside additional ankle protectors. Dried-out flowers were also present, contributing to dirt and debris on the floor and on top of the television stand. Observations conducted of room [ROOM NUMBER], revealed that four bedside dressers were dusty, tray tables had visible food spills, and the windowsills were also dusty and had not been cleaned. These findings were confirmed by Licensed Nurse Employee E6. On April 25, 2025, at approximately 10:30 a.m., a meeting with the Administrator, Employee E1, it was confirmed that housekeeping staff are not consistently maintaining resident rooms, including regularly dusting dressers and wiping tray tables. On April 25, 2025, at 2:30 p.m., a second observation was conducted with the Housekeeping Supervisor, Employee E4, who confirmed that room [ROOM NUMBER]A had not been cleaned or sanitized since the passing of Resident R10 on April 22, 2025. 28 Pa. Code 201.18(b)(1) Management 395791 Page 3 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, and interviews with staff and residents, it was determined that the facility did not ensure that residents were free of misappropriation of resident property related to diversion of narcotic medication for two of 24 residents records reviewed (residents R69 and R262). Residents Affected - Some Findings include: Review of clinical documentation for Resident R69 revealed that she was admitted to the facility on [DATE], and had diagnoses including of dementia (progressive degenerative disease of the brain), chronic pain and arthritis (join inflamation). Conintued review of the resident's clinical record revealed that the resident signed on to receive hospice care in February 2024. Review of Resident R69's [DATE] physican orders revealed an order obatined dated [DATE], for Morphine sulphate .20MG (milligrams)/ML .give 0.25 ml by mouth every four hours as needed for pain. Review of her most recent MDS (Minimum Data Set, a periodic assessment of resident care needs) section C, Cognitive Patterns, dated [DATE], revealed that the resident had a BIMS (Brief Interview for Mental Status, an assessment of orientation and memory recall) score of 9 out of 15, indicating moderate impairment. Review of clinical documentation for Resident R262 revealed that she was admitted to the facility on [DATE], and had diagnoses including, but not limited to, dementia, chronic pain and arthritis. Further review showed that she signed on for hospice care on [DATE]. A physician order, dated [DATE], was noted which stated, Morphine sulphate .20MG/ML .give 0.25 ml by mouth every 6 hours as needed for SOB (shortness of breath)/pain. Review of records also revealed that the resident had died on [DATE]. Review of a facility reported incident from [DATE], revealed that on that date, licensed nurse Employee E32, upon administering a dose of morphine to resident R262, noted that the color of the liquid in the bottle was a paler blue than usual. She also noted a mint-like smell to the liquid, and that the bottle cap was incorrect. On further investigation, it was noted by the facility that the color, smell, and bottle cap were all consistent with the facility house stock mouthwash. An investigation was initiated, and all liquid morphine in the facility was reviewed for signs of tampering. The morphine bottle for resident R69 was also found to be altered in color and to have a minty smell. No other morphines were noted to appear to be tampered with. An email dated [DATE], stated that independent laboratory testing confirmed that the concentration of the morphine for resident R262 was 3.88 MG/ML, confirming that it had been diluted. Interview with Resident R69 on [DATE], at 1:15 p.m. revealed that she felt that her pain management had been adequate and that she did not suffer an increase in pain related to the morphine diversion. At the time of the interview, the resident was alert and oriented. Interview with the Nursing Home Administrator, Employee E1, and the Director of Nursing, Employee E2, on [DATE], at 2:30 p.m. confirmed that the Morphine for Residents R69 and R262 had been misappropriated. Employee E1 stated that all nurses with access to the medication had been tested for opiates; all nurses tested negative. He further stated that the local police department had been contacted but had declined to investigate the matter. 395791 Page 4 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0602 28 Pa. Code 201.14(a)(b) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.29(a) Resident rights Residents Affected - Some 395791 Page 5 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policies and procedures, employee personnel records, and staff interviews, it was determined that the facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employees' employment history for two of six newly hired employees reviewed. (Employees E26 and E29) Residents Affected - Few Findings include: A review of the Facility Policy titled Abuse revised on June 30, 2023, revealed Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/ patient (hereinafter patient), and exploitation for all patients. The center will implement an abuse prohibition program through the following: Screening of potential hires: training of employees (both new employees and ongoing training for all employees. A review of the Licensed Practical Nurse (LPN), Employee E26's personnel file revealed that Employee E26 was hired on March 1, 2025, and criminal background was done April 1, 2025. Register nurse (RN), Employee E29 was hired on January 1, 2025, and had her criminal background done on January 8, 2025. An interview was conducted with Human Resources, staff, Employee E30 on April 25, 2025, sat 1:42 p.m., it was confirmed both LPN, Employee E26 and RN, Employee E29 had their criminal background done after their hire date. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.19 Personnel policies and procedures 395791 Page 6 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one incident related to the provision of incontinence care for one of 23 residents reviewed. (Resident R 30). Residents Affected - Few Findings include: Reviewed the facility policy title Abuse date on June 30, 2023 stated Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/ patient ( hereinafter patient) property, and exploitation for a patients. Neglect is the failure of the facility, its employees or service providers to provide goods and service to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident R30's clinical record revealed that the resident was admitted to the facility on [DATE], with a BIMS (Brief interview for mental status) of 8 and diagnosies of Alzheimer's Disease (progressive degenerative disease of the brain), encephalopathy (disease that affects the brain function or structure), Parkinson's disease (progressive disease of the central nervous system), and Angina (chest pain). Review of the facility investigation report revealed that Resident R30 had his call bell on approximately at 1:45 pm on June 11, 2024, nurse manger entered room to answer call bell and found the resident with wet sheets. The resident stated that he had not been changed, there were darker stains on the sheet. Resident R30 stated he did not know when he was changed last. The nurse manager asked resident's roommate if he was cared for, he stated he was changed but did not remember what time. Furthermore, after review of interview with staff, time of incident was between 1:00-2:00 PM on June 11, 2024 after multiple discussion with staff on the unit 7-3 on June 6, 2025, it was determined that nurse aide Employee E31 did infact did not complete the 2 hour round and check and change of Resident R30 who was assigned to her. Review the investigation it was revealed that investigation was incomplete. It only had one statement from the nurse Employee E14. The incident had more staff and residents interviewed but the investigation didn't have any other witness statements from nursing aides, other staff and residents. An interview was held with director of nursing employee E2 on April 23, 2025, at 2:33 p.m., and it was confirmed that the investigation was incomplete due to missing witness statements from other staff and residents. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 395791 Page 7 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans for oxygen therapy (Resident 10), a safety device and elopement (Resident R73) and a repositioning program (Resident R82) for three of 23 residents reviewed (Resident R10, R73, R82). Findings include: A review of the policy titled Comprehensive Care Plans dated February 25, 2025 revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan or each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Review of Resident R10's clinical record revealed that the resident was initially admitted to the facility on [DATE]; diagnosed with emphysema (chronic lung condition), dyspnea (shortness of breath). Review of clinical record indicated that Resident R10 was ordered, dated March 25, 2025, oxygen at 2 Liters/Min, via nasal cannula, as needed for diagnosis of dyspnea (shortness of breath). Review of Resident R10's care plan with Registered nurse, Employee E5 confirmed that there was no care plan plan developed for the resident receiving oxygen therapy. A review of the clinical record for Resident R73 revealed that she/he was admitted to the facility on [DATE], and was at risk for elopement. The physician order dated March 18, 2025, revealed a safety device (wander guard) to left ankle -check placement. On April 23, 2025, at approximately 2:37 p.m. an interview with the Directive of Nursing, Employee E2, confirmed that Resident R73 did not have a care plan for the safety device and/or for being at risk for elopment. Review of facility policy Turning and repositioning, implemented on September 1, 2024, revealed all residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to medical condition. The frequency of turning and repositioning will be documented in the resident's plan of care. Review of Resident R82 's clinical record revealed that Resident R82 was admitted to the facility on [DATE] with diagnoses of, but not limited to, Dementia (progressive degenerative disease of the brain), Heart failure, Type 2 Diabetes (failure of the body to produce insulin) and Acute Kidney failure. Review of Resident R82' s MDS (Minimum Data Set- resident assessment of care needs) revealed that resident had a BIMS (Brief interview for mental status) of 6, indicating resident was not cognitively intact. 395791 Page 8 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R82's clinical record revealed Resident R82 has a Stage III (ulcer involving full thickness of skin loss) pressure ulcer on right buttocks that initially presented on March 10, 2025 as a DTI (deep tissue injury) and a Stage III pressure ulcer on sacrum that initially presented on March 3, 2025 as a MASD (Moisture associated skin damage). Interview with Rehab Director, Employee E11 on April 23, 2025 at 1:45 pm revealed that Resident R82 needed to be prompted to be repositioned, otherwise the resident would not be able to do it himself. Review of Resident R82 's care plan revealed Resident R82 had the potential impairment to skin integrity related to fragile skin, decrease mobility, aging, incontinence, history of weight loss. No documented evidence of care plan for resident to be turned and repositioned. Interview with Director of Nursing, Employee E2 on April 23, 2025 at 2:00 pm revealed no care plan in place for turning and positioning for Resident R82. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c)(d) Resident care policies 395791 Page 9 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to provide activities of daily living (ADL) assistance necessary to maintaining good grooming for one out of 4 residents reviewed. ( Resident 24) Residents Affected - Few Findings include: A review of the clinical record of Resident R24 revealed admission date of August 31, 2022, with diagnosis of chronic atrial fibrillation (irregular rapid heart beat), osteoarthritis, adult failure to thrive, low back pain. Review of Resident R24's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated March 7, 2025, revealed a Brief Interview for Mental Status (BIMS- is a screening test that aides in detecting cognitive impairment) indicated a score of 13 which revealed that the resident was cognitively intact. The section of Functional Abilities indicated that Resident R24 requires maximum assist with personal hygiene. On April 22, 2025, at 12:00 p.m., an observation conducted with Licensed Nurse Employee E12 confirmed that Resident R24 had long and dirty fingernails. Resident R24 expressed a desire to have his fingernails trimmed. On April 23, 2025, at 12:39 p.m., a second observation with Licensed Nurse Employee E12 revealed that Resident R24's right thumbnail remained untrimmed and dirty. Employee E12 stated she was unsure why all the resident's nails had not been cut. 28 Pa Code 211.12(d)(5) Nursing services 395791 Page 10 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to provide pressure ulcer treatment, consistent with professional standards of practice, for one of two residents reviewed for pressure ulcers (Resident R106). Residents Affected - Few Findings Include: Review of facility policy Pressure Ulcer Prevention dated July 1, 2024, revealed to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Review of Resident R106 's clinical record revealed that Resident R106 was admitted to the facility on [DATE]. Resident R106 has right heel Stage 3 (ulcer involving full thickness of skin loss). Review of Resident R106's comprehensive care plan revised on February 4, 2025, revealed Resident R106 has impaired tissues integrity with a right heel wound and interventions included to offload heel when in bed and heel protectors while in bed to offload. Observation on April 25, 2025, at 11:25 a.m. of Resident R106 revelaed that the resident was in bed sleeping, there was no heel boot on the resident's right foot and the right heel was not offload. Interview with Nurse aide, Employee E22 on April 25, 2025, at 11:10 a.m. reported that resident had a boot in his closet and the boot was only applied at nighttime. Nurse aide, Employee E22 confirmed that the right heel was not offload when Resident R106 was observed in bed. Interview with the Nurse unit manager, Employee E3 on April 25, 2025, at 11:15 a.m. confirmed that Resident R106 rigth heel was not offloaded. 28 Pa. Code 211.12 (d)(5) Nursing services 28 Pa. Code 211.10(c)(d) Resident care policies 395791 Page 11 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews with staff and policy and procedure review, it was determined that the facility failed to implement nutritional interventions for one of three residents at nutritional risk related to pressure sore development and deteriation of wounds. (Resident R82) Residents Affected - Few Findings include: A review of the policy titled nutritional management dated September 1, 2025 revealed that it was the responsibility of the facility to provide care and services to ensure that each resident maintained acceptable parameters of nutritional status related to his/her medical condition. The policy also indicated that the facility was responsible for revising ntritional interventions based on identification and routine assessment of resident's care needs. A review of the undated policy titled weight assessment and intervention revealed that it was the multidisciplinary teams' responsibility to prevent monitor and intervene for unplanned weight loss for the residents. The policy indicated that weekly weights would be obtained at the discretion of the interdisciplinary team. The policy indicated that the physician and dietitian would be notified of unplanned changes in weight. The policy indicated that the dietitian was responsible for making recommendations to the physician for the management of the weight change. Care planning for weight loss or impaired nutrition would identify the root cause of the weight loss. A review of the undated policy titled charting and documentation revealed that all care planning and changes to the medical, physical, functional or psychosocial condition of the resident shall be documented in the medical record. The facility staff were responsible for documention all care specific details for each resident including: treatment provided and date, assessment data, unusual findings, intolerances, and notification of the physician and the family as needed. Clinical record review revealed a quarterly comprehensive assessment dated [DATE] for Resident R82 that indicated this resident was cognitively impaired. The assessment indicated that Resident R82 had diagnoses that included: dementia, anemia, malnutrition and swallowing disorder. The assessment also indicated that this resident was seventy-four inches in height and was ordered a mechanically altered diet. The assessment said that Resident R82 was at high risk for pressure ulcer development and this resident had unhealed unstageable pressure ulcers. Clinical record review revealed a wound specialist progress note dated March 10, 2025. The progress note indicated that Resident R82 was evaluated with a scrotal surgical wound, left plantar foot deep tissue injury, and a newly identified sacral maceration and right ischial deep tissue injury. Interview with the wound specialist, Employee E17, at 1:30 p.m., on March 23, 2025 confirmed the status of the alterations in skin intergrity for Resident R82. Clinical record review revealed a dietitian assessment dated [DATE] that indicated Resident R82 was prescribed the 8 ounces of the house supplement (ensure plus or two calorie HN) once a day, to promote weight gain and skin healing. The nursing staff were responsible for the administration of the house supplement (Ensure plus or two calorie HN) once a day, to promote weight gain and skin healing. Clinical record review revealed on February 1, 2025 Resident R82 weighed 172 pounds. On March 25, 395791 Page 12 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2025 Resident R82 weighed 162 pounds. This was a significant 5 % weight loss over one month. Resident R82's usual body weight was recorded at 170 pounds. Resident R82's ideal body weight was recorded at 190 pounds +/- 10%. There was no documentation to indicate that the nursing staff notified the dietitian of the significant weekly weight loss from March 19, 2025 (a weight was recorded at 165 pounds for resident R82) through March 25, 2025 (a weight was recorded at 162 pounds ). There was also no documentation to reflect that a nutritional assessment had been completed for Resident R82 on or after March 25, 2025. Clinical record review revealed a wound specialist progress note dated April 14, 2025 that indicated Resident R82 was being evaluated for the sacral wound that had evolved to a Stage III (ulcer involving full thickness of skin loss) pressure ulcer and a stage III pressure ulcer of the right ischial area. The physician indicated that Resident R82 was at risk for wound development and deterioration of skin with diagnoses of poor nutritional status and protein calorie malnutrition. Interview with the wound care specialist, Employee E17, at 1:30 p.m., on April 23, 2025 confirmed the progression of the skin brealdown for Resident R82. Clinical record documentation review revealed that the nursing staff were not administering the house supplement as care planned by the dietitian during the months of March and April, 2025. Interview with the dietitian, Employee E16, at 1:00 p.m., on April 24, 2025 confirmed that the house supplement was not being administered during March or April, 2025 as care planned to meet the nutritional needs of Resident R82. During the interview with the dietitian, it was also confirmed that diagnostic data related to nutritional assessment and care planning was not available for review during the month of April, 2025. 28 Pa. Code 211.10(a)(b)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 PA. Code 211.5(f)((i)(ii)(iii)(iv)(vii)(viii)(ix)(x) Medical records 395791 Page 13 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory, tracheostomy and tracheal suctioning care and services for four of 23 residents reviewed (Resident R1, R10, R72, R51). Residents Affected - Few Findings include: Review of the Facility Policy titled Oxygen Administration last revised July 1, 2024, indicated that The purpose of this procedure is to provide guidelines for safe oxygen administration. It further stated under Preparation verify that there is a physician's order. Review of Resident R10's clinical record revealed that the resident was initially admitted to the facility on [DATE]; diagnosed with emphysema (chronic lung condition), and dyspnea (shortness of breath). Review of clinical record indicated that Resident R10 was ordered, dated March 25, 2025, oxygen at 2 Liters/Min, via nasal cannula, as needed for diagnosis of dyspnea. On April 22, 2025, at 12:22 p.m. an observation with Registered nurse, Employee E5 confirmed that Resident's R10 oxygen level was at 5-liter, oxygen tubing was not labeled. Employee E5 reported that her oxygen level was changed yesterday, and she did not change the order in the clinical record. It was further confirmed there was no order to change the oxygen tubing on weekly bases. Review of Resident R72's clinical record revealed that the resident was initially admitted to the facility on [DATE]; diagnosed with acute respiratory failure with hypoxia, chronic obstructive pulmonary disease. Review of clinical record indicated that Resident R72 was ordered, dated April 8, 2025, oxygen tubing changed weekly, label each component with date and initials, every shift every Sunday label each component with date and initials. On April 22, 2025, at 12:24 p.m. observation with Registered nurse, Employee E5 confirmed that Resident's R72 tubing was not labeled with date or initials. Review of facility policy Tracheostomy Care, implemented on September 1, 2024, revealed Tracheostomy care will be provided according to the physician's orders, comprehensive assessment and individualized care plan such as monitoring for resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate. General considerations include: a. provide tracheotomy care at least twice a day, b. maintain a suction machine, a supply of suction catheters, correctly sized cannulas and an Ambu bag easily accessible for immediate emergency care. Review of facility policy Tracheostomy Care- Suctioning, implemented on September 1, 2024, revealed the facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such care consistent with professional standards of practice, the comprehensive person- centered care plan and resident goals and preferences. Tracheal suctioning is performed by a licensed nurse to clear the throat and upper respiratory tract of secretions that may block airway. 395791 Page 14 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R1 s clinical record revealed that Resident R1 was admitted to the facility with diagnoses of, but not limited to, Acute Respiratory Failure, Pneumonia, COPD (Chronic Obstructive Pulmonary Disease), Tracheostomy ( allows air to pass into windpipe to help with breathing). Review of Resident R1's MDS (Minimum Data Set) on April 25, 2025 revealed that resident has a BIMS (Brief interview for mental status) of 7, indicating resident was not cognitively intact. Review of Resident R1's comprehensive care plan on April 25, 2025 revealed that resident has a tracheostomy related to impaired breathing mechanics. Intervention includes to suction the resident as needed. Review of Resident R1's clinical record revealed a physician order date April 9, 2025 to change disposable inner cannula. Further review of the clinical record revealed a physician order dated March 14, 2025 for Trach Care every day and night shift and Trach/ oral suction every day and night shift. Observation of Trach Care for Resident R1 on April 25, 2025 at 9:30 a.m. revealed that suctioning equipment was not at bedside. During trach care, Resident R1 was observed to be coughing and de-sating after inner cannula was replace. Licensed Nurse, Employee E20 left resident's bedside to retrieve suction cannula and tubing from medication room. Interview with Director of Nursing, Employee E2 on April 25, 2025 at 11:00 a.m. confirmed suction supplies should be at bedside at all times for a resident with a tracheostomy. Clinical record review for Resident R51 revealed a quarterly comprehensive assessment dated [DATE] that indicated that this resident was cognitively impaired. The assessment also indicated that this resident had pulmonary diagnoses of respiratory failure and chronic obstructive pulmonary disease. Clinical record review revealed that Resident R51 was hospitalized on [DATE] for sygns and symptoms of shortness of breath. The nursing staff noted that the resident's pulse oximeter reading was 80-88%, before transfer to the emergency medical team. Clinical record review for Resident R51 revealed a physician's order dated April 8, 2025 for the use of oxygen therapy. The physician order indicated that the nursing staff were to administered oxygen at 2 liters per minute via nasal cannula continuously The physician also gave orders for the licensed nursing staff to monitor pulse oximeter readings every day shift. Resident R51 was observed at 10:30 a.m., on April 25, 2025 seated in the wheel chair in the dining room, with no staff members in attendance. The resident was observed with an empty oxygen tank attached to the wheel chair and the tubing placed inside the resident's nostrils. The licensed practical nurse, Employee E19, confirmed that the resident was placed in the dining room without adequate oxygen therapy. 28 Pa Code 211.12(d)(5) Nursing services 395791 Page 15 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure proper pain management interventions were provided for one of 23 residents reviewed (Resident R48). Residents Affected - Few Findings include: Review of facility policy Pain Management, last reviewed on March 6, 2025, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Review of Resident R48's clinical record revealed that Resident R48 was admitted to the facility on [DATE] with diagnoses of, but not limited to, COPD (Chronic obstructive pulmonary disease), contracture of left knee, osteoarthritis of right shoulder. Review of Resident R48's comprehensive care plan on April 22, 2025 revealed that resident exhibited or was at risk for alterations in functional mobility related to contracture deformity. There was no documented evidence of care plan for pain management. Review of Resident R48's quarterly MDS (Minimum Data Set) dated February 28, 2025, revealed that resident has a BIMS (Brief interview for mental status) of 12, indicating resident is cognitively intact. Interview with Resident R48 on April 22, 2025 at 10:45am revealed that ResidentR48 had a lot of pain when rolled to his right side and reported telling multiple staff members every time they change me not to turn to right side however they do not listen and do it anyway and it causes a great deal of pain and discomfort. Interview with Clinical Regional Nurse, Employee E13, on April 23, 2025 at 10:00am revealed that resident expresses pain related contracture on right side and pain is increased when rolled to that side. Confirmed no care plan in place to prevent rolling the resident on his right side. Review of Resident R48 s clinical record on April 23, 2025, revealed a task for resident to be rolled Left and Right every 2-3 hours. Interview with Clinical Regional Nurse, Employee E13, on April 23, 2025 at 10:00 am confirmed task in place to roll resident to right and left side. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 395791 Page 16 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observations and staff interview, it was determined that the facility failed to address the care needs of a resident when answering call bells for one of 23 residents reviewed (Resident R29), and did not ensure sufficient staffing was maintained on a daily basis for all nursing units. (2nd and 3rd floors) Findings include: During a resident council meeting on April 24, 2025, at 10:00 a.m. with six residents, (Residents R37, R36, R81, R84, R89, and R31) who were identified as being alert and oriented, reported that call bells were not answered in a timely manner and staff were coming in and turn off the call bells without providing assistance. On April 24, 2025, at 11:07 a.m., an observation was made of Resident R29 lying flat in bed. The resident, who is non-verbal and communicates using head nods and facial expressions, clearly indicated a desire to be transferred into her wheelchair. The surveyor recommended the use of the call bell, and Resident R29 pressed it at 11:08 a.m. On April 24, 2025, at 11:11 a.m., Licensed Nurse, Employee E6 responded to the call. Upon entering the room, Licensed Nurse, Employee E6 asked the resident what she needed. Resident R29 pointed to her wheelchair, indicating she wanted to be transferred. Licensed Nurse, Employee E6 informed her that she had been changed and that her assigned nurse aide would be in to assist with the transferring the resident out of bed. Licensed Nurse, Employee E6 then turned off the call bell and exited the room. On April 24, 2025, at 11:22 a.m., the surveyor observed Nurse aide, Employee E24 walking through the hallway and asked whether she had been notified of Resident R29's need for a transfer. Nurse aide, Employee E24 reported that she had not been informed and stated her role was to provide transport and respond to call bells. Interview with Nurse aide, Employee E25, who was also present in the hallway near the room where Resident R29 lived stated that she had not been informed of the resident's need and that Resident R29 was not part of her caseload. The surveyor proceeded to the nursing station, where approximately four staff members were seen conversing. Licensed Nurse E6 was observed working at the computer. Employee E6 explained that the nurse aid assigned to Resident R29 was occupied with cleaning another room and stated, she's unable to do everything. Shortly thereafter, Employee E25 volunteered to assist and called upon Employee E24 to help. Resident R29 was transferred to her wheelchair at 11:26 a.m. Since the call bell was turned off by Employee E6 and there was no further indication that Resident R29 needed help. On April 24, 2025, at 2:55 p.m. an interview was conducted with the Administrator, Employee E1 who confirmed that staff members should not be turning off the call bells without ensuring that the resident's needs are addressed. 395791 Page 17 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of nursing care staffing levels revealed that the facility failed to meet the state required minimum number of 3.2 care hours per patient per day (PPD) on five of 21 days reviewed (February 9, 14 and 15, 2025, and April 20 and 22, 2025), and did not meet the state required minimum Nurse Aide staffing ratios on 13 of 21 days reviewed (February 9-15, 2025, and April 18-20, and 22-24, 2025). In an interview with the staffing coordinator, employee E33, on April 24, 2025, at 2:30 p.m., she confirmed that the staffing levels did not meet state minimum requirements and stated that the facility was always understaffed. 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 211.12(f.1)(3)(4) Nursing services 28 Pa Code 211.12(i)(2) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a)(3) management 395791 Page 18 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on obervations, review of facility policy, review of employee personnel files and interviews with staff, it was determined that the facility did not ensure staff was qualified and competent to perform tracheostomy care and suctioning care for one of one resident reviewed (Resident R1). Findings Include: Review of facility policy Orientation, implemented on September 1, 2024, revealed it is the policy of this facility to develop, implement and maintain an effective orientation process for all new staff, individuals providing services under a contractual arrangement and volunteers, consistent with their expected roles. Further review of section Policy Explanation and Compliance Guidelines part 6., Competency evaluation form process: section e., the completed form represents initial competency in skills needed to care for residents and perform job functions. Review of facility policy Tracheostomy Care- Suctioning, implemented on September 1, 2024, revealed the facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such care consistent with professional standards of practice, the comprehensive person- centered care plan and resident goals and preferences. Tracheal suctioning is performed by a licensed nurse to clear the throat and upper respiratory tract of secretions that may block airway. Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility with diagnoses of, but not limited to, Acute Respiratory Failure, Pneumonia (an infection of the aire sacs), COPD (Chronic Obstructive Pulmonary Disease), and Tracheostomy (allows air to pass into windpipe to help with breathing). Review of Resident R1's clinical record revealed a physician order date April 9, 2025 to change disposable inner cannula. Further review of the clinical record revealed a physician order dated March 14, 2025 for Trach Care every day and night shift and Trach/oral suction every day and night shift. Observation of Trach Care for Resident R1 on April 25, 2025 at 9:30 a.m. revealed that suctioning equipment was not at bedside. During trach care, Resident R1 was observed to be coughing and de-sating after inner cannula was replace. Licensed Practical Nurse, Employee E20 left resident's bedside to retrieve suction cannula and tubing from medication room. Interview with Director of Nursing, Employee E2 on April 25, 2025 at 11:00 a.m. confirmed suction supplies should be at bedside at all times for a resident with a tracheostomy. Interview with Licensed Practical Nurse, Employee E20 on April 25, 2025 at 11:30am revealed staff receives no training or in-service from facility to confirm competency in Tracheostomy Care or Suctioning. Interview with Directory of Nursing, Employee E2 on April 25, 2025 at 12:30pm confirmed no documented evidence of Tracheostomy Care or suctioning competencies for Licensed Practical Nurse, Employee E20. Further Review of Facility's employee personnel files on April 25, 2025 at 12:30 p.m revealed no documented evidence of Tracheostomy Care or suctioning competencies completed by any licensed nursing 395791 Page 19 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0726 staff in facility. Level of Harm - Minimal harm or potential for actual harm Interview with Director of Nursing, Employee E2 on April 25, 2025 at 1:00pm confirmed no documented evidence of completed Tracheostomy care or suctioning competencies for any licnesed nursing staff in facility. Residents Affected - Few 28 Pa Code 201.19(6)(7) Personnel policies and procedures 28 Pa Code 201.20(b)(d) Staff development 28 Pa. Code 211.12(d)(1) Nursing services 395791 Page 20 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of facility provided documentation and interview with staff, it was determined that facility did not ensure annual performance evaluation was completed for three nurse aides out of three nurse aides' trainings reviewed (Employee E21, E22 and E23) Residents Affected - Some Findings include: Review of facility policy titled Required Training Certification and Continuing Education on Nurse Aides, revised in 2024, indicates that the facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. Review of facility provided performance evaluations on Thursday, April 25, 2025, revealed that nurse aides, Employees E21, E22 and E23 did not have any 12 hours of in-service training. Interview with Development Coordinator on April 25, 2025, at 1:40 p.m, confirmed that there was no 12 hours of in-service training annually. 28 Pa Code 201.19(2) Personnel policies and procedures 395791 Page 21 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of facility records and staff interviews, it was determined that facility did not ensure that the narcotic reconciliation record was complete related to missing signatures and initials on the narcotic count sheet for three of three medication carts reviewed. (2nd Floor Medication Cart, and two medication carts on 3rd Floor) Findings include: Review of Facility In-service Shift to Shift count, implemented in October 2024, revealed nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. Observation of Medication Cart on 2nd Floor on April 24, 2025 at 2:20 p.m., revealed multiple missing signatures during the month of April 2025 for oncoming and outgoing nurses on Narcotic Reconcilation Sheet. Licensed Practical Nurse, Employee E9. confirmed at the time of the observation that the narcotic reconcilation sheet was missing signatures from oncoming and outgoingt nurses confirming the narcotic count. Observation of Medication Cart on 3rd Floor on April 24, 2025 at 2:33 p.m., revealed multiple missing signatures during the month of April 2025 for oncoming and outgoing nurses on Narcotic Reconcilation Sheet. It was confirmed on April 24, 2025 at 2:33 p.m. by Licensed Practical Nurse, Employee E10. Observation of a second Medication Cart on 3rd Floor on April 24, 2025 at 2:45 p.m., revealed multiple missing signatures during the month of April 2025 for oncoming and outgoing nurses on Narcotic Reconcilation Sheet. It was confirmed on April 24, 2025 at 2:45pm by Licensed Practical Nurse, Employee E20. Interview with Clinical Regional Nurse, Employee E13 on April 25, 2025 at 10:00am, confirmed missing signatures and missing initials on the narcotic reconciliation sheets. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services 395791 Page 22 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based observations and staff interviews, it was determined that facility did not ensure that opened medications were properly labeled with the date that the medication was opened for two of three medication carts reviewed and one of one medication room reviewed. (2nd floor medication cart, 3rd floor medication cart and 2nd floor medication room). Findings include: Observation of Medication cart on 2nd floor on April 24, 2025 at 2:20 pm revealed 5 opened bottles of medication, including B12, Cranberry, Vitamin D, Ferrous Sulfate and B1, not labeled with an open date. Interview with Licensed nurse, Employee E9 on April 24, 2025 at 2:21pm confirmed 5 opened bottles of medication not labeled with an open date. Observation of Medication Cart on 3rd floor on April 24, 2025 at 2:33pm revealed 1 opened bottle of medication, including Vitamin D 1250mg, not labeled with an open date. Interview with Employee E10 on April 24, 2025 at 2:35 pm confirmed 1 open bottle of Vitamin D, no label with open date. Observation in 2nd Floor Med Room on April 24, 2025 at 2:25pm revealed open bottle of Tuberculin with no open date labeled. Interview with Employee E9 on April 24, 2025 at 2:26pm confirmed open bottle of Tuberculin with no open date labeled. 28 Pa. Code 211.12 (d)(1) Nursing services. 395791 Page 23 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations of the food and nutrition services department, reviews of policies and procedures and interviews with staff and residents, it was determined that the facility failed to ensure that foods and drinks were being served palatable, attractive and at safe and appetizing temperatures during meal times for the residents. (Third floor, noon meal) Resident council (Residents R37, R36, R81, R84, R89, and R31) Residents Affected - Some Findings include: A review of the facility's policy titled resident test tray assessment dated April, 2025 indicated that hot food entrees and vegetables were to be served at a temperature of 130 degrees Fahrenheit and all cold foods and beverages were to served at 45 degrees Fahrenheit. The temperatures were established to ensure safety and resident satisfaction at point of service, with the foods and fluids prepared by the food service department. On April 22, 2025, at 12:54 p.m., an interview was conducted with Resident R15, who stated that the food at the facility is terrible. Observation of the resident's plate revealed that only a piece of bread, juice, and ice cream had been consumed from the lunch tray. Observations of the tray line assembly area in the main kitchen , where foods are prepared for delivery to the nursing unit revealed that cold food items (sandwiches: cheese, turkey and cheese and turkey salad platters) were not being held cold. The time and temperature sensative food items were placed on an open cart in the middle of the main kitchen and held throughout the meal trayline preparation for delivery to the nursing units. Interview with the director of dietary services, Employee E15 at 11:30 a.m., on April 23, 2025 revealed that since the food service equipment was broken (reach-in refrigerator unit); we have not been able to hold the prepared cold food items under refrigeration. Observations of the lowerator (heated pellet drop in dispenser unit) at 11:30 a.m., on April 23, 2025 revealed that this piece of food service epuipment was not fully functioning. One of the drop in dispenser units was not warm. The pellets were cool to touch. The other two dispensers were not hot; that was the pellets were lifted out of the dispensers with out using the handle that was designed for lifting hot pellets with ease. The internal temperature of the heated pellet drop in dispenser unit ranges from 250 to 290 degrees Fahrenheit when fully operational. Dietary staff were required to use gloves or a handle to lift the pellet and place it in the pellet holder on the residents' meal trays during tray line and assembly of foods and drinks. Observations of the steam table located in the main kitchen of the dietary services department revealed that it was not fully operational. The dietary staff had to have a large bucket to catch and contain the constant leaking of the water place inside the wells of the unit. The dietary cooks were documenting hot food holding temperatures of 145 degrees Fahrenheit for hot foods. Observations of the built in steam table located in the bistro part of the dietary services department on the first floor of the facility revealed that two of the four wells in that unit were not fully functioning. A test tray evaluation was completed on the Third floor nursing unit with the director of dietary 395791 Page 24 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some service, Employee E15, during the noon meal service for the residents on April 23, 2025. Observations of the noon meal service on the third floor nursing unit revealed that hot food and cold fodd items were not being served to the residents at appetizing temperatures. A test tray was evaluation on the April 23, 2025 during the noon meal service on the third floor revaled a glazed ham glazed 3 ounces was planned on the menu however only a two ounce potion was given. The temperature of the glazed ham at point of service was 115 degrees Fahrenheit. The vegeatables planned on the menu were steamed cabbage and baked sweet potatoes. The temperature of the foods tested at 116 degrees Fahrenheit. The dessert planned on the menu was a cranberry crunch bar. The residents were served angel food cake with cranberry sauce. The angel food cake and cranberry sauce was slanted side ways and attempted to be portioned in a small bowl. The director of dietary services said that the dietary staff ran out of small cake plates. The drinks were coffee milk and fruit punch. The time temperature sensative milk was served at 60 to 67 degrees Fahrenheit. The foods and fluids served on April 23, 2025 were not appetizing, attractive, portion specific or at safe satisfying temperatures for the residents. The facility policy for point of service temperatures were have hot food served at 130 degrees Fahrenheit and cold foods to be served at 45 degrees Fahrenheit. During a resident council meeting on April 24, 2025, at 10 a.m. on the second floor with six residents, (Residents R37, R36, R81, R84, R89, and R31) who were identified as being alert and oriented, reported that food is served cold, uncooked meat, overcooked vegetables, fish served very smells and not getting night snacks. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 395791 Page 25 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations of the food and nutrition services department, it was determined that foods were not being stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: Observations on March 22, 2025 of the main kitchen where foods and beverages were stored, prepared and assembled for distribution and service to the residents revealed that the low temperature dish machine was not fully functioning since March 14, 2025. The director of dietary service could not demonstrate with the use of litmus test strip that the hypochlorite was registering an acceptable 50 ppm (parts per million) to effectively sanitize the dishes, utencils, pots, pans, cups, bowls, plates and trays for resident and dietary staff use. Interview with the Director of Dietary Services, Employee E15 revealed that the main kitchen operation had been waiting on a customized part (squeeze tube and rinse assembly metal connector) for the mechanics of the dish machine, since March 14, 2025. All of the dome lids and plate holders contained a white film like substance, which the Director of Dietary Services reported was calcium and magnesium deposits from the hard water (water high in mineral content) usage. The Director of Dietary Services reported that there was no water softener in operation inside the food and nutrition services department. The flooring in the dish room area was water damaged and in need of repair. The grouting surrounding the floor drain and throughout the dish room was warn away leaving the grooves between the ceramic floor tiles with constant stagnant water and food debris. Ceramic floor tiles were missing and broken that were near the floor drain. The flooring in the dish room underneath the dish machine contained a build up of food debris, sludge and moist dirt. The basic white drop ceiling tiles above the dish machine area contained dried food debris that was splattered across the ceiling. The white drop ceiling tiles above the hot food cooking (gas stove, grill and oven) and preparation area contained a film of grease. The tiles were observed to be light yellow instead of white there original color. The wall area behind the dish machine across the lip of the flight type dish machine and its' attachment to the wall, contained a black substance resembling mold. Observations on March 22, 2025 of the alcove that was adjacent to the dish machine and ice machine revealed that there was piping in this area that was not funneled to the floor drain. A constant flowing of water was noted on the floor in this area along with a white green and black tinged film. The wall area where the pipe was attached was water damaged. The plaster board was damp and cracking. The walk-in refrigerator unit was heavily soiled. The walls and floors of this refrigerator contained a build-up of dirt, food spillage and white film-like substances. The air circulation fan screens were soiled with dust, dirt. The large metal food storage racks were soiled with sticky food pieces. The shelving was also soiled with dirt and rust. The lighting inside this walk-in refrigerator unit was dull; making the refrigerator not easily cleanable. 395791 Page 26 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The reach-in refrigerator and reach-in freezer units were not function. The Director of Dietary Services, Employee E15, reported that it has been for several months without the use of the reach-in refrigerator or freezer units. The preparation sink was leaking water onto the flooring while dietary staff were using it to prepare foods. The steam table was leaking water onto the flooring tray line assembly. Dietary staff were using bins to collect the water as it leaked from the sinks and steam table unit inside the main kitchen. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3)(e)(1)(2.1)(3) Management 395791 Page 27 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review, staff interview and review of facility policy, it was determined that the facility failed to ensure that clinical records wer completed for one of 23 clinical records reviewed. (Resident R82) Findings include: Review of facility policy Turning and repositioning, implemented on September 1, 2024, revealed all residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to medical condition. The frequency of turning and repositioning will be documented in the resident's plan of care. Review of Resident R82 's clinical record revealed that Resident R82 was admitted to the facility on [DATE] with diagnoses of, but not limited to, Dementia (progressive degenerative disease of the brain), Heart failure, Type 2 Diabetes (failure of the body to produce insulin) and Acute Kidney failure. Review of Resident R82' s MDS (Minimum Data Set- resident assessment of care needs) revealed that resident had a BIMS (Brief interview for mental status) of 6, indicating resident was not cognitively intact. Review of Resident R82's clinical record revealed Resident R82 has a Stage III (ulcer involving full thickness of skin loss) pressure ulcer on right buttocks that initially presented on March 10, 2025 as a DTI (deep tissue injury) and a Stage III pressure ulcer on sacrum that initially presented on March 3, 2025 as a MASD (Moisture associated skin damage). Interview with Rehab Director, Employee E11 on April 23, 2025 at 1:45 pm revealed that Resident R82 needed to be prompted to be repositioned, otherwise the resident would not be able to do it himself. Review of Resident R82 s clinical record revealed task in place for resident to be turned and reposition every 2-3 hours side to side while in bed. No documented evidence that task was completed. Interview with the Director of Nursing, Employee E2 on April 23, 2025 at 2:00pm confirmed no documented evidence of task to turn and reposition resident every 2- 3 hours side to side while in bed was completed. 28 Pa. Code 211.12(d)(1) Nursing services 395791 Page 28 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to store bed linens in a sanitary environment, increasing the risk of infection and contamination. (Laundry room) Residents Affected - Some Findings: A review of the policy titled 'Laundry Services revised July 1, 2024, it revealed the facility lauders and delivers linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. On April 22, 2025, at 1:23 p.m., a tour of the laundry area located in the basement was conducted with the housekeeping supervisor, Employee E4, where laundry operations occur. During the tour, it was observed and confirmed that new linens were unfolded and placed directly on the bare floor inside the extra linen closet. These linens were neither boxed nor covered, leaving them exposed to potential contamination. Additionally, an inspection of the second-floor linen closet revealed that clean pillows, although sealed in plastic bags, were stored directly on the floor. Extra pads use for a mechanic lifts, were not sealed or protected, were also found stored on the floor. 28 Pa. Code 201.18(b)(3) Mangement 395791 Page 29 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews with dietary and administrative staff, it was determined that essential food service equipment was not maintained in safe operating condition. Residents Affected - Few Findings include: Observations on March 22, 2025 of the main kitchen where foods and beverages were stored, prepared and assembled for distribution and service to the residents revealed several pieces of equipment that were not fully functioning. Observations of the dish machine revealed that it was not being maintained according to manufacturer's recommendations. The low temperature dish machine was not fully functioning since March 14, 2025. The director of dietary service could not demonstrate with the use of litmus test strip that the hypochlorite was registering an acceptable 50 ppm (parts per million) to effectively sanitize the dishes, utencils, pots, pans, cups, bowls, plates and trays for resident and dietary staff use. Interview with the director of dietary services, Employee E15 revealed that the main kitchen food service operation had been waiting on a customized part (squeeze tube and rinse assembly metal connector) to effectively and safely operate the dish machine, since March 14, 2025. Observations of the tray line assembly area in the main kitchen on April 22 and April 23, 2025, where foods are prepared for delivery to the nursing units, revealed that cold food items (sandwiches: cheese, turkey and cheese and turkey salad platters) were not being held cold. These time and temperature sensitive food items were placed on an open cart in the middle of the main kitchen and held throughout the meal trayline preparation and then delivery to the nursing units. Interview with the director of dietary services, Employee E15 at 11:30 a.m., on April 23, 2025 revealed that since the food service equipment was broken (reach-in refrigerator unit and reach-in freezer unit); dietary staff have not been able to hold the prepared cold food items under refrigeration on the assembly line or quick chill in the freezer on the assembly line. Observations of the lowerator (heated pellet drop in dispenser unit) at 11:30 a.m., on April 23, 2025 revealed that this piece of food service epuipment was not fully functioning. One of the drop in dispenser units was not warm. The pellets were cool to touch. Dietary staff were lifting the pellets without hand protection. The other two dispensers were not hot; meaning the pellets were lifted out of the dispensers with out using the handle that was designed for lifting hot pellets with ease. The internal temperature of the heated pellet drop in dispenser unit ranges from 250 to 290 degrees Fahrenheit when fully operational. Dietary staff were required according to manufacturer's recommendations to use gloves or a handle to lift the pellet and place it in the pellet holder on the residents' meal trays during tray line and assembly of foods and drinks. Observations on April 22, 2025 of the steam table located in the main kitchen of the dietary services department revealed that it was not fully operational. The dietary staff had to have a large bucket to catch and contain the constant leaking of the water from the steam table well. According to manufacturer's recommendations water added to the the wells of the unit. The dietary cooks documented hot food holding temperatures of 145 degrees Fahrenheit for foods. Observations on April 23, 2025 of the built in steam table unit located in the bistro on the first 395791 Page 30 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few floor of the building revealed that two of the four wells in that unit were not fully functioning. The bistro was part of the dietary services that were operated by the food and nutrition services department. Interview with the administrator, Employee E1, at 11:00 a.m., on April 24, 2025 confirmed the lack maintenance to ensure that essential food service equipment ( dish machine, lowerator, reach-in refrigerator, reach-in freezer unit and steam tables) was in safe mechanical and electrical condition to operate the food and nutrition services department. 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(3) Management 395791 Page 31 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, review of the pest control logs and the pest control operator's management program, review of policies and documentation, it was determined that the facility failed to maintain an effective pest control program in the kitchen and one of two nursing units. (3rd Floor Nursing Unit and Kitchen) Residents Affected - Few Findings include: A review of facility Pest Control policy revised July 1, 2024, states that It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pest and rodents. On April 22, 2025, at 12:00 p.m., an observation conducted with Licensed Nurse Employee E12 confirmed that Resident R24 had gnat flies in his room. Employee E12 further stated that always had gnat flies' issues. On April 24, 2025, at 9:45 a.m., an interview was conducted with the Maintenance Director, Employee E8, who reported that the facility receives pest control treatments on a weekly basis. However, a review of pest control invoices for the past three months revealed that treatments were actually conducted twice a month. Invoices reviewed included service dates of January 10 and 29, 2025; February 7 and 21, 2025; March 7 and 21, 2025; and April 4 and 18, 2025. There was no documentation supporting weekly pest control visits. A review of the facility's pest control logbooks from January 24, 2025- April 18, 2025, did not reveal any documentation for the gnat flies in room [ROOM NUMBER]. Review of the pest control invoices from January 10, 2025, through April 18, 2025, there was no treatment conducted in room [ROOM NUMBER] for gnats. The only gnat activity documented was in the following reports of March 7 and 21, 2025. Review of pest invoice on March 7, 2025, revealed Inspected and treated through lobby, nursing stations, kitchen, laundry room, employee break room, office personnel's physical therapy and lounges for general pest. Inspected and treated 2nd floor and 3rd floor staff restrooms for roach activity. Battled and placed monitors. Nursing staff on 3rd floor verbally reported heavy gnat activity in room [ROOM NUMBER]. Recommend to utilized logbooks. No reports written in other logbooks. Review of the pest invoice on March 21, 2025, revealed inspected and treated 3rd floor room [ROOM NUMBER] for gnat and fly activity. Spoke with Admin. Observations of the food and nutrition services department on April 22, 2025 revealed that the flooring directly underneath the dish machine was heavily soiled with food debris, dirt and sludge There were areas of pooling water and food debris in the gaps/grooves between the ceramic tiled flooring throughout the dish machine area. The floor in this area was surrounded by deep grooves from water damage. Many of the ceramic tiles were missing or broken. The adjacent alcove contained a wall area with holes and a dampened, loose wall board. This was noted with the constant dripping of water on to the floor. The piping dripping the water was not aligned with the floor drain. The lack of housekeeping and maintenance of the dish room provided places for pests and rodents to live and breed. 395791 Page 32 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The drop ceiling tiles above the dish machine contained dried food splatter across the front of the panels. The ceiling tiles above the hot food preparation area contained a film of cooking grease that was covering the panels. The lack of housekeeping provided food for pests to live and breed. The preparation sink in the main kitchen was leaking water onto the flooring while it was in use. The steam table in the main kitchen was leaking water onto the floor; unless dietary staff used a bin to capture the water. The lack of maintenance of equipment allowed easy access to food for pests and rodents. A review of the pest control operators reports for the months of January, February, March and April, 2025 revealed that the main kitchen was being treated for common household pests and rodents (roaches and mice). The consulting pest control operator documented active roach observations in January, 2025, for the main kitchen. The consulting pest control operator documented active mice observations in April, 2025, for the main kitchen. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 395791 Page 33 of 34 395791 04/25/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031
F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on personnel record review, and staff interview, it was determined that the facility failed to provide abuse, neglect and exploitation training at the time of hire for four of six staff reviewed (Employee E26, E27, E28, and E29). Findings: A review of the Facility Policy titled Abuse revised on June 30, 2023, revealed Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/ patient (hereinafter patient), and exploitation for all patients. The center will implement an abuse prohibition program through the following: Screening of potential hires: training of employees (both new employees and ongoing training for all employees. Reviewed six new hires employee records revealed the following: -Licensed practical nurse, Employees E26 hired on March 1, 2025, abuse training was not completed until April 2, 2025, -Register nurse,Employee E27 was hired on February 10, 2025, abuse training was completed until March 14, 2025. -Nurse aide, Employee E28 was hired on March 1, 2025, abuse training was completed until on April 11, 2025. -Register nurse, Employee E29 was hire on January 1, 2025, there was no documented evidence that abuse training was completed. An interview was conducted with Human Resources staff, Employee E30 on April 25, 2025, sat 1:42 p.m., it was confirmed that the employees above had late abuse training done, and one register nurse didn't have the abuse training done. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.19(8) Personnel policies and procedures 395791 Page 34 of 34

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Back to top

Citations

23 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0550GeneralS&S Dpotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0697GeneralS&S Dpotential for harm

    F697 - Pain Management

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0725GeneralS&S Epotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0730GeneralS&S Epotential for harm

    F730 - Regular in-service education

    Observe each nurse aide's job performance and give regular training.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    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.

  • 0602GeneralS&S Epotential for harm

    F602 - The resident has the right to be free from abuse, neglect, misappropriation of re

    Protect each resident from the wrongful use of the resident's belongings or money.

  • 0607GeneralS&S Dpotential for harm

    F607 - The facility must develop and implement written policies and procedures that:

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  • 0610GeneralS&S Dpotential for harm

    F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the

    Respond appropriately to all alleged violations.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0686GeneralS&S Dpotential for harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0692GeneralS&S Dpotential for harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0726GeneralS&S Dpotential for harm

    F726 - Nursing Services

    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  • 0755GeneralS&S Dpotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0761GeneralS&S Dpotential for harm

    F761 - Labeling of Drugs and Biologicals

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • 0804GeneralS&S Epotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0908GeneralS&S Dpotential for harm

    F908 - Maintain all mechanical, electrical, and patient care equipment in safe

    Keep all essential equipment working safely.

  • 0925GeneralS&S Dpotential for harm

    F925 - Maintain an effective pest control program so that the facility is free of

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  • 0943GeneralS&S Dpotential for harm

    F943 - Abuse, neglect, and exploitation

    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

FAQ · About this visit

Common questions about this visit

What happened during the April 25, 2025 survey of COMPLETE CARE AT HARSTON HALL LLC?

This was a inspection survey of COMPLETE CARE AT HARSTON HALL LLC on April 25, 2025. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at COMPLETE CARE AT HARSTON HALL LLC on April 25, 2025?

Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Share this reportEmail

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.