Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harborview Rehabilitation And Care Center At Lansd during CMS and state inspections, most recent first.
A resident with cervical disc disorder and edentulism did not have care plans developed or implemented for recommended cervical ROM exercises or dental needs. Staff confirmed the absence of a restorative nursing program, no documentation of ROM exercises, and no care plan addressing denture use or the resident's complaints of pain with dentures.
Two residents with behavioral and mental health diagnoses engaged in close interactions, including kissing and being alone together, which were observed and reported by staff but not documented in their clinical records. Despite staff awareness and intervention, the facility failed to maintain complete and accurate documentation of these events as required by policy.
A resident with psychosis and schizophrenia, who expressed dissatisfaction with the facility environment and food, was able to leave the facility without a comprehensive elopement care plan in place. The resident was later found offsite and returned without injury. Facility leadership confirmed the absence of a person-centered care plan addressing elopement risk.
The facility failed to serve hot beverages at safe temperatures, resulting in a burn injury to a resident. Additionally, inadequate supervision led to another resident with dysphagia consuming inappropriate food, causing a choking incident and aspiration pneumonia. These deficiencies highlight lapses in adherence to safety protocols and supervision requirements.
The facility failed to store drugs and biologicals according to professional standards in two medication storage rooms. On the 2nd floor, Latanoprost eye drops requiring refrigeration were improperly stored in a medication cart. On the 3rd floor, expired nutritional supplements and medications were found, including Glucerna and Simethicone drops. These deficiencies were confirmed with staff members.
The facility failed to promptly resolve grievances related to billing, room changes, and missing items for several residents. A resident with heart failure experienced delays in room change requests and issues with missing orthopedic shoes, while another resident with multiple sclerosis faced unresolved billing concerns. Additionally, residents were not informed about the status of the activity van, leading to dissatisfaction and a violation of resident rights.
The facility failed to provide timely podiatry care for two residents, one with Type II Diabetes and another with multiple sclerosis, both requiring regular foot care due to their conditions. Despite recommendations for follow-up treatment every 60 days, no further podiatry appointments were scheduled after July 2024, as confirmed by the DON.
A resident with dysphagia and other health conditions choked on a hoagie due to insufficient supervision during meals, despite having a care plan requiring supervision. The facility lacked enough nursing staff to oversee residents with behavioral health needs, resulting in the resident developing aspiration pneumonia.
The Nursing Home Administrator and DON failed to manage hot beverage temperatures, resulting in a resident burn. Coffee was served at unsafe temperatures, contrary to facility policy, leading to a blister on a resident's hip. Staff were unaware of the policy and did not check temperatures before serving.
The facility failed to implement enhanced barrier precautions for several residents, as required by their policy. During an observation, it was noted that there was no signage or PPE for residents with specific medical conditions necessitating such precautions, including those with Foley catheters, feeding tubes, and infections. An interview confirmed the lack of policy implementation.
The facility did not maintain safe water temperatures across all floors, as reported by residents and confirmed by surveyors. Two residents experienced temperature fluctuations, with one noting a sudden increase while showering. The facility lacked a specific water temperature policy, relying on state regulations. Surveyors found temperatures exceeding the 110-degree limit, and the Maintenance Director identified a faulty regulator as the issue.
The facility failed to ensure that a staff member completing the MDS was licensed to practice nursing in Pennsylvania. Employee E15, working remotely from outside the U.S., completed and signed multiple sections of the MDS for several residents without a valid nursing license. Interviews revealed a lack of awareness and documentation regarding her licensing status, with the Director of Nursing and Administrator unable to provide a copy of her license.
A facility failed to provide ASL translation for a resident's representative during a care plan meeting, despite the representative's need for such services due to being deaf. The facility's policy only accommodated translation services if the resident required it, leading to a deficiency in communication. Staff communicated with the representative through writing, but did not provide a sign language interpreter, as the facility was unwilling to cover the associated costs.
The facility failed to notify the State Long Term Ombudsman of emergency transfers and discharges for three residents. One resident was discharged to the hospital and did not return, another was discharged and cut off by insurance, and a third was discharged, readmitted, and discharged again without returning. The facility lacked a process for notifying the Ombudsman.
The facility failed to maintain functioning air conditioning units across all three nursing units, affecting resident rooms and dining areas. Observations revealed several PTAC units were non-functional, with issues such as not blowing cool air and having detached front panels. Residents reported discomfort due to warm room conditions. Facility documentation indicated multiple units required repairs, including cooling section and control box replacements.
Failure to Develop and Implement Care Plans for ROM and Dental Needs
Penalty
Summary
The facility failed to develop and implement a person-centered care plan addressing both range of motion (ROM) and dental needs for a resident diagnosed with Cervical Disc Disorder with Myelopathy. The resident was discharged from occupational therapy with recommendations for cervical ROM exercises, but there was no evidence that these exercises were performed or documented. Interviews with facility staff, including the Director of Nursing, confirmed that there was no restorative nursing program in place at the time and no care plan related to cervical ROM for the resident. Additionally, the resident was observed to be edentulous and not wearing dentures due to pain, instead gumming food during meals. The resident reported needing new dentures, and staff interviews confirmed the absence of a care plan addressing dental needs, denture use, or the resident's preferences and complaints regarding dentures. The Minimum Data Set (MDS) did not accurately reflect the resident's edentulous status, and there was no documentation or care planning for non-compliance with denture use or for the resident's dental discomfort.
Failure to Document Resident Interactions and Behavioral Events
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents with behavioral and mental health diagnoses. Specifically, the clinical records for two residents, both with histories of dementia, mood disorders, anxiety, depression, and bipolar disorder, did not reflect significant events and interactions that occurred between them. Although social services and staff were aware of a close relationship between the two residents, including kissing and being alone together in private areas, these interactions were not documented in the residents' progress notes over the past three months. Staff interviews confirmed that such events occurred, and that staff intervened and reported the incidents to nursing management, but there was no corresponding documentation in the clinical records. Additionally, the facility's policy on behavior management and monitoring was not followed as required, as evidenced by the lack of documentation regarding the residents' interactions and the behavioral concerns that prompted room changes and increased monitoring. The absence of accurate and complete records for these residents, despite their complex behavioral histories and the facility's awareness of their interactions, constitutes a failure to maintain medical records in accordance with accepted professional standards.
Failure to Develop and Implement Elopement Care Plan for Resident with Psychosis and Schizophrenia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing elopement risk for a resident with a history of psychosis and schizophrenia. The resident was admitted with significant mental health diagnoses, including psychosis and schizophrenia, which are associated with symptoms such as hallucinations, delusions, and disorganized thinking. Despite these risk factors, the clinical record review showed that no care plan was in place to address the resident's risk of elopement. On April 23, 2025, the resident was discovered missing from his room, prompting a search and notification of local authorities, facility administration, and the resident's guardian. The resident was later found at a local convenience store and returned to the facility without injury. Interviews with the resident revealed ongoing dissatisfaction with the facility environment and food, as well as a stated intent to leave again if possible. The Administrator and DON confirmed that the care plan was not comprehensive regarding elopement prevention and resident safety.
Failure to Ensure Safe Beverage Temperatures and Proper Supervision
Penalty
Summary
The facility failed to ensure that hot beverages were served at safe temperatures, resulting in an Immediate Jeopardy situation for residents on the First Floor. The coffee was served at 178 degrees Fahrenheit, exceeding the facility's policy limit of 165 degrees. This led to Resident R97 sustaining a burn on the left hip after spilling the hot coffee. The resident, who had no cognitive impairments, required assistance with setup or cleanup for eating. The incident was not immediately addressed, as the nurse aide did not take the temperature of the coffee before serving it and was unaware of the facility's policy. Additionally, the facility failed to properly supervise Resident R9, who had a history of respiratory failure, dysphagia, and other conditions, resulting in actual harm. The resident, with moderate cognitive impairment, was on a mechanical soft diet but consumed a hoagie, leading to a choking episode that required the Heimlich maneuver. The resident subsequently developed aspiration pneumonia. The care plan for Resident R9 included supervision during meals, which was not adequately provided, allowing the resident to eat food not in accordance with diet orders. The facility's lack of adherence to its policies and inadequate supervision of residents led to these incidents. The dietary and nursing staff were not aware of the temperature requirements for serving hot beverages, and the supervision of residents with dietary restrictions was insufficient, resulting in harm to Resident R9. These deficiencies highlight the need for strict adherence to safety protocols and proper supervision to prevent accidents and ensure resident safety.
Removal Plan
- Facility reviewed and updated the hot liquids policy.
- Prior to hot liquids leaving Dietary, a temperature will be taken by Dietary staff.
- Before serving to residents a temperature will be taken by CNA (nurse aide)/Nurse and be documented.
- If the hot liquid temperature is > 150 degrees, it will not be served and will be cooled down by using ice until the temperature is below 150 degrees.
- The facility will inservice more than 90% of staff and will be at 100%.
- The facility will do audits to ensure effectiveness of staff in-service using questionnaire and/or on the spot interview and results to be reviewed in QAPI.
- The facility to audit temperature daily for one week and twice a week for two weeks and weekly for two months and reported and discussed in QAPI.
Improper Storage and Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to professional standards of practice in two out of three medication storage rooms observed. On the 2nd floor unit, an eye drop medication, Latanoprost 0.005%, which required refrigeration before opening, was found in the medication cart instead of being refrigerated. This finding was confirmed with a licensed nurse, Employee E18. Additionally, on the 3rd floor unit, an expired nutritional supplement, Glucerna with carb steady, was found with an expiration date of November 1st, 2024, and was intended for a resident who had not yet received it. Further inspection revealed 19 more expired nutritional supplements in an unsealed box in the medication storage room. The facility's policy mandates that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures. However, observations on the 2nd floor unit revealed several expired medications, including Vitamin B-6, Diphenhydramine Hcl, Reguloid, Bisacodyl suppository, Major sore throat spray, and Zinc Sulfate. These findings were confirmed with the Unit manager, Employee E19. Similarly, on the 3rd floor unit, expired medications such as Mommy's bliss - baby gas relief - Simethicone drops were found, confirmed with licensed nurse, Employee E20. The facility's failure to adhere to its medication storage policy resulted in the presence of expired and improperly stored medications.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances and concerns raised by residents, as evidenced by interviews, clinical records, and resident council minutes. Eleven residents attending the resident council and two additional residents had unresolved issues related to billing clarification, the status of the activity van, room change requests, and missing items. The facility's grievance policy mandates attempts to resolve concerns within three business days, with unresolved issues reported to the Nursing Home Administrator (NHA). However, this policy was not effectively implemented, as residents reported delays and lack of communication from the social worker and other staff. Resident R26, who was admitted with a primary diagnosis of heart failure, expressed frustration over the lack of response from the social worker regarding a request to share a room with her husband, Resident R80. Despite being informed that they would be placed together when a room became available, there was no follow-up, and the resident's missing orthopedic shoe further complicated her care. Occupational Therapy notes indicated that the missing shoe hindered her ability to transfer, yet the issue remained unresolved, with the resident being advised to purchase new shoes. Resident R41, diagnosed with multiple sclerosis, also experienced communication issues with the social worker regarding billing concerns. The resident disputed claims of making appointments that incurred charges to the facility and requested to see the bills, but received no response. Additionally, residents expressed dissatisfaction with the lack of updates on the activity van, which had been out of service since March. The NHA acknowledged the van's status but had not communicated this to the residents, leading to further grievances. The facility's failure to address these concerns violated resident rights as outlined in 28 Pa. Code 201.29(a)(i).
Failure to Provide Timely Podiatry Care for Residents
Penalty
Summary
The facility failed to ensure proper foot care for two residents, Resident R26 and Resident R41, as per professional standards of practice. Resident R26, who was admitted in November 2020, has diagnoses of heart failure and Type II Diabetes, which can increase the risk of foot injuries due to nerve damage. Despite being alert and oriented, Resident R26 reported not being seen by a podiatrist since a scheduled appointment on July 10, 2024, which recommended follow-up treatment in 60 days. However, there was no evidence of any further podiatry appointments in the resident's clinical records. Similarly, Resident R41, admitted in September 2021 with multiple sclerosis, which can cause numbness and pain in the feet, also reported not receiving timely podiatry care. The last documented podiatry appointment for Resident R41 was on July 10, 2024, with a recommendation for follow-up treatment in 60 days. The facility's failure to schedule further podiatrist appointments for both residents was confirmed by the Director of Nursing on November 15, 2024, indicating a lapse in maintaining the residents' foot health as required by professional standards.
Insufficient Nursing Staff Leads to Choking Incident
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure the safety of residents, specifically impacting one resident, identified as Resident R9. This resident has a complex medical history, including dysphagia, bipolar disorder, Parkinsonism, and schizophrenia, which necessitates special dietary and supervision needs. On July 15, 2024, Resident R9 experienced a choking incident while eating a hoagie in the dining room, despite having a physician's order for a mechanical soft diet. The incident required the Heimlich maneuver and resulted in a diagnosis of aspiration pneumonia, for which the resident was treated with antibiotics. The investigation revealed that Resident R9 was not properly supervised during the meal, as the facility did not have enough nursing staff to oversee residents with behavioral health needs. The resident's care plan, which identified a risk for choking and aspiration due to dysphagia, included interventions for supervision during meals. However, these interventions were not implemented until after the choking incident. An interview with a licensed nurse confirmed the lack of sufficient staff to supervise residents adequately, leading to the deficiency cited under F 689 and relevant state codes.
Failure to Manage Hot Beverage Temperatures Leads to Resident Burn
Penalty
Summary
The Nursing Home Administrator and Director of Nursing failed to manage the facility effectively, leading to an Immediate Jeopardy situation. The deficiency involved serving hot beverages at unsafe temperatures, resulting in a burn injury to a resident. The facility's policy on hot liquid management, which required coffee to be served at temperatures not exceeding 165°F, was not adhered to. Observations revealed that coffee was being served at temperatures as high as 182.8°F, and staff were unaware of the policy or how to check the temperature before serving. The incident involved a resident with no cognitive impairments who accidentally spilled hot coffee on himself, resulting in a blister on his left hip/buttock area. The resident required treatment with Silvadene cream. Staff interviews confirmed that the temperature of the coffee was not checked before serving, and the dietary and nursing aides were not aware of the facility's policy regarding safe serving temperatures. The Nursing Home Administrator acknowledged the oversight and the potential risk it posed to residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for several residents, as required by their policy revised in June 2023. This policy mandates the use of gowns and gloves during high-risk activities for residents colonized or infected with targeted or epidemiologically important multidrug-resistant organisms (MDROs). During an observation tour on November 19, 2024, it was noted that there was no enhanced barrier precaution signage or personal protective equipment (PPE) available for four residents with specific medical conditions that necessitated such precautions. These residents included one with a Foley catheter for hydronephrosis and urinary retention, another with a feeding tube, a third with a foot ulcer and osteomyelitis requiring a PICC line for intravenous antibiotics, and a fourth with a chronic eye infection. Additionally, the facility did not provide enhanced barrier precaution signage for two other residents who were on barrier precautions. One of these residents had carbapenem-resistant enterobacterales, and the other had a Foley catheter, Candida auris, and a sacral pressure ulcer. An interview with the Registered Nurse Assessment Coordinator and Infection Preventionist confirmed the lack of implementation of the facility's policy, as there was no signage or PPE provided for the residents mentioned. This deficiency was noted under the Pennsylvania Code regulations regarding the responsibility of the licensee and nursing services.
Water Temperature Deficiency Across Facility Floors
Penalty
Summary
The facility failed to maintain safe and comfortable water temperatures for residents, staff, and the public across all three floors. During a group meeting with 11 residents, two residents from the second floor reported issues with water temperature fluctuations, with one resident experiencing a sudden increase in water temperature while showering. An interview with the Nursing Home Administrator revealed that the facility lacked a specific policy on water temperatures, relying instead on state regulations of 110 degrees. However, surveyors recorded water temperatures exceeding this limit, with readings of 115.5 degrees on the first floor and 112.4 degrees in the third-floor shower room. The second-floor shower room registered a temperature of 106 degrees, which changed to colder when the faucet was slightly adjusted. The Maintenance Director identified the need for a new regulator for the faucet.
Unlicensed Staff Completing MDS Assessments
Penalty
Summary
The facility failed to ensure that staff completing the Minimum Data Set (MDS) were properly licensed and registered to practice nursing in Pennsylvania. Employee E15, who works remotely from outside the United States, was found to have completed and signed multiple sections of the MDS for several residents without holding a valid nursing license in Pennsylvania. The Pennsylvania Licensing System Verification website confirmed that Employee E15's name was not listed in the database for nurses licensed to practice in the state. Interviews with the Director of Nursing and the Administrator revealed a lack of awareness and documentation regarding Employee E15's licensing status. The Director of Nursing acknowledged that Employee E15 worked remotely and did not have a copy of her nursing license. The Administrator initially claimed that Employee E15 was performing clerical work and did not require a license, but later admitted that she had completed assessment portions of the MDS. An interview with another RNAC confirmed that Employee E15 completed some sections of the MDS, which were then verified by the RNAC.
Failure to Provide ASL Translation for Resident's Representative
Penalty
Summary
The facility failed to provide American Sign Language (ASL) translation for a resident's representative during a care plan meeting, which is a violation of the resident's right to receive notices in a format and language they understand. The resident, who was admitted with multiple diagnoses including Dysphagia, Anxiety, Type 2 Diabetes, and others, had a Power of Attorney (POA) for medical care. The resident's daughter, who is deaf and uses sign language, required an interpreter for the care plan meeting. However, the facility's policy did not accommodate this need, as they stated they would only provide translation services if the resident themselves required it. Interviews with facility staff, including the Social Worker and Nursing Home Administrator, revealed that the facility was aware of the representative's need for a translator but chose not to provide it due to associated costs. The facility communicated with the family member through writing when she was present at the facility, but did not provide a sign language interpreter for the care plan meeting. The family member declined to use her own interpreter over the phone, leading to the deficiency in communication during the care planning process.
Failure to Notify Ombudsman of Emergency Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long Term Ombudsman of facility-initiated emergency transfers and discharges for three residents. Resident R10 was discharged to the hospital and did not return after hospitalization. Resident R8 was discharged to the hospital, was cut off by insurance, and did not return. Resident R9 was discharged to the hospital, readmitted, and then discharged again, not returning after the second hospitalization. The facility documentation lacked evidence of notification to the Ombudsman for these discharges. An interview with the Nursing Home Administrator revealed that the facility did not have a process in place for providing the Ombudsman with discharge notices.
Non-Functioning Air Conditioning Units in Facility
Penalty
Summary
The facility failed to ensure that the air conditioning units (PTAC units) were functioning properly across all three nursing units, including the 1st, 2nd, and 3rd floors. During observations conducted with the Maintenance Director, several PTAC units in resident rooms and dining areas were found to be non-functioning. Specific issues included units not blowing cool air, units with front panels hanging off, and units that were completely non-functional. Residents confirmed that their rooms felt warm, indicating discomfort due to the malfunctioning air conditioning units. The facility documentation review further revealed that multiple PTAC units required repairs, such as cooling section replacements, control box installations, and front cover repairs. The deficiencies were confirmed with the Maintenance Director during the observations. The report cites violations of 28 Pa Code 201.14 (a) and 28 Pa. Code 201.18(b)(1), which pertain to the responsibility of the licensee and management, respectively.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lansdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elm Terrace Gardens | 0.2 mi | — | 2 | 0 |
| St Mary Center For Rehabilitation & Healthcare | 0.8 mi | — | 15 | 0 |
| Montgomeryville Skilled Nursing And Rehabilitati | 2 mi | — | 0 | 0 |
| Gwynedd Healthcare And Rehabilitation Center | 2 mi | — | 4 | 0 |
| Dock Terrace | 3.1 mi | — | 4 | 0 |
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