Harmony at Harts Run.

“Prescription medication container pharmacy label was missing the 'as needed' portion of the physician order. The label indicated 'Take 1 tablet by mouth daily at bedtime' but did not include the additional instruction that the resident 'may take 1 additional tablet by mouth at bedtime as needed.'”

“Directions for operating the secured dementia care unit (SDCU) courtyard gate locking mechanism were not conspicuously posted near the device at the time of inspection (10:38am).”

“A resident's personal financial information was stolen by former staff and used to open a credit card in the resident's name, resulting in unauthorized charges. Additionally, another staff member attempted to cash a check belonging to a resident.”

“Walk-in refrigerator temperature was 41°F (exceeds 40°F maximum); walk-in freezer temperatures ranged from 5-10°F (exceeds 0°F maximum); ice cream freezer lacked thermometer and had temperature of 8°F.”

“Open and unsealed box of Bran Flakes found on pantry shelf in kitchen. Repeat violation from 12/19/2023 and 3/4/2024.”

“Fire drill conducted on 9/30/2024 at 4:22 AM resulted in evacuation time of 20 minutes, 9 seconds, exceeding the maximum 15 minutes specified by fire safety expert documentation dated 2/5/24.”

“Resident initial medical evaluation did not record the resident's pulse rate or the medical professional's license number; both areas of the form were left blank.”

“Resident assessment indicated 'Moderate (Immobile)' for mobility with Level of Assistance-Evacuation: Moderate, but resident was admitted to secured dementia care unit and actually requires total physical or oral assistance from one or more staff persons to evacuate in an emergency.”

“Resident support plan did not document the medical care and services to be provided by Commonwealth Hospice, including showering, toileting, personal hygiene, and incontinence care, despite the resident's admission to hospice being documented in the assessment.”

“The Licensing Inspection Summaries (LIS) posted on the bulletin board on the first floor near the elevators did not include the most recent full renewal LIS completed 9/27/23. The facility failed to post current inspection summaries as required.”

“The home did not immediately report suspected abuse of a resident to the appropriate protective services. On the date of the incident, staff person A shouted at and berated resident #1 in the dining room, making the resident feel embarrassed, humiliated, attacked, and singled out. The home did not report this incident to the local Area Agency on Aging/Protective Services until several days later.”

“When allegations of abuse involving a staff person were reported, the home did not immediately develop and implement a plan of supervision or suspend the staff person. Staff person A continued working shifts after the incident and was not suspended until days later, and no plan of supervision was submitted to the Department.”

“The home failed to report an incident involving suspected abuse to the Department's personal care home regional office within 24 hours as required. The abuse incident occurred on the inspection date, but the Department was not notified within the required timeframe.”

“Resident records were not provided to Department agents immediately upon request. Records were requested at approximately 10:00 AM but not provided until 11:23 AM.”

“An undated food plate containing beef, rice, peas, a roll, soup, and cherry cake was found in the 1st floor pub refrigerator at 10:50 AM. Leftover food must be labeled and dated.”

“Multiple open and unsealed food items were found in the walk-in freezer, dry food storage room, and secured dementia care unit kitchen, including: corn, beef patties, baby carrots, cookie dough, graham crackers, vanilla mousse mix, polenta, grits, quick bread, and potato chips. This was a repeat violation from 12/19/2023 and 9/27/2023.”

“Resident medical evaluation dated 10/5/23 indicates "see attached" under the medication addendum section; however, nothing was attached to the medical evaluation. This was a repeat violation from 12/19/2023.”

“Resident is prescribed capsule medications to take 1 capsule by mouth 2 times a day. At approximately 3:00 PM, capsules were present in resident blister pack; however, the resident narcotic count sheet indicated pills were present because the 8:00 AM administration on 3/4/24 was not recorded on the resident narcotic count sheet at the time of medication administration.”

“Violation of general facility requirements under 55 Pa Code § 2600.103(g).”

“Violation of requirements under 55 Pa Code § 2600.187(d).”

“Violation of requirements under 55 Pa Code § 2600.141(a).”

“Violation of requirements under 55 Pa Code § 2600.185(a).”

“Violation of requirements under 55 Pa Code § 2600.224(a).”

“Violation of requirements under 55 Pa Code § 2600.225(a).”

“Facility issued a THIRD PROVISIONAL license based on failure to submit an acceptable plan to correct noncompliance items and failure to comply with acceptable plan to correct noncompliance items related to 55 Pa Code Chapter 2600.”

“Resident #1's medical evaluation does not indicate the need for a secured dementia care unit. Resident #2 was admitted to the Secure Dementia Care Unit but the medical evaluation was not completed within 60 days prior to admission. Resident #3 was admitted to the Secure Dementia Care Unit without a diagnosis of dementia and the medical evaluation was not completed timely.”

“Resident #2 was admitted to the Secure Dementia Care Unit but the preadmission screening including the cognitive screening was not completed within 72 hours prior to admission.”

“Violation related to secured dementia care unit requirements under 55 Pa Code § 2600.234(a).”

“Violation related to secured dementia care unit requirements under 55 Pa Code § 2600.234(a).”

“Violation of general facility requirements under 55 Pa Code § 2600.103(g).”

“Facility issued a THIRD PROVISIONAL license based on failure to submit an acceptable plan to correct noncompliance items and failure to comply with acceptable plan to correct noncompliance items related to 55 Pa Code Chapter 2600.”

“Violation of requirements under 55 Pa Code § 2600.187(d).”

“Violation of requirements under 55 Pa Code § 2600.141(a).”

“Violation of requirements under 55 Pa Code § 2600.185(a).”

“Violation of requirements under 55 Pa Code § 2600.224(a).”

“Violation of requirements under 55 Pa Code § 2600.225(a).”

“Resident #1's medical evaluation does not indicate the need for a secured dementia care unit. Resident #2 was admitted to the Secure Dementia Care Unit but the medical evaluation was not completed within 60 days prior to admission. Resident #3 was admitted to the Secure Dementia Care Unit without a diagnosis of dementia and the medical evaluation was not completed timely.”

“Resident #2 was admitted to the Secure Dementia Care Unit but the preadmission screening including the cognitive screening was not completed within 72 hours prior to admission.”

“Violation of requirements under 55 Pa Code § 2600.225(a).”

“Violation of requirements under 55 Pa Code § 2600.224(a).”

“Violation related to secured dementia care unit requirements under 55 Pa Code § 2600.234(a).”

“Violation of general facility requirements under 55 Pa Code § 2600.103(g).”

“Violation of requirements under 55 Pa Code § 2600.187(d).”

“Violation of requirements under 55 Pa Code § 2600.141(a).”

“Violation of requirements under 55 Pa Code § 2600.185(a).”

“Facility issued a THIRD PROVISIONAL license based on failure to submit an acceptable plan to correct noncompliance items and failure to comply with acceptable plan to correct noncompliance items related to 55 Pa Code Chapter 2600.”

“Resident #1's medical evaluation does not indicate the need for a secured dementia care unit. Resident #2 was admitted to the Secure Dementia Care Unit but the medical evaluation was not completed within 60 days prior to admission. Resident #3 was admitted to the Secure Dementia Care Unit without a diagnosis of dementia and the medical evaluation was not completed timely.”

“Resident #2 was admitted to the Secure Dementia Care Unit but the preadmission screening including the cognitive screening was not completed within 72 hours prior to admission.”

“Two incidents of abuse were substantiated. In the first incident, a staff person slapped a resident multiple times on the forearms and pulled the resident's ponytail while assisting the resident to the dining room. In the second incident, a staff person pushed a resident over the arm of a sofa, causing the resident to fall onto the sofa. This is a repeat violation.”

“A resident's most recent medical evaluation does not indicate the need for the resident to continue to be served in the secured dementia care unit (SDCU), though the resident was admitted to the SDCU. This is a repeat violation.”

“A medication technician handed a resident all morning dose medication blister cards to review, and the resident subsequently took them to the dining room unsecured. Medications were not kept locked in the medication cart at all times as required.”

“A resident's initial assessment incorrectly documented the resident as independent with ambulation (code A) when the resident actually uses a rollator walker for assistance with ambulation.”