Harborview Rehab: Care Plan Failures for Spine Patient - PA
Harborview Rehabilitation and Care Center at Lansdale failed to develop care plans for the woman's physical therapy needs and dental problems, according to a federal inspection completed August 21.
The resident, identified as R93 in the report, has cervical disc disorder with myelopathy — a condition where spinal cord compression can cause weakness, numbness and pain. Her occupational therapist discharged her May 29 with specific recommendations for cervical range of motion exercises.
Nobody followed through.
Director of Rehab Employee E8 confirmed the May discharge with cervical ROM recommendations during an August 21 interview. But Director of Nursing Employee E2 told inspectors the facility had no restorative nursing program and was "just starting to develop" one.
Employee E2 confirmed there was no documented evidence the cervical range of motion was ever performed. She also confirmed there was no care plan related to the exercises.
The facility's lack of a restorative program meant therapeutic recommendations fell through the cracks. Employee E2 revealed they didn't even have a policy for restorative nursing.
Meanwhile, the resident struggled with a separate problem that affected her daily nutrition. During an August 18 observation at 12:26 AM, inspectors found her eating breakfast without dentures.
The woman told inspectors she has dentures "but it hurts so she does not use it and that she needs new ones."
Her medical records showed she was edentulous — having no natural teeth. But staff had incorrectly coded her federal assessment, marking "No natural teeth" as "NO" when it should have been "YES."
More troubling, nursing staff seemed unaware of her dental struggles.
RNAC Employee E7 confirmed during an August 20 interview that the resident was edentulous and had full dentures. But Employee E7 said there was no dental care plan developed and admitted being unaware that the resident complained of denture pain.
A speech therapist, Employee E8, had evaluated the resident for swallowing problems and confirmed she wasn't wearing her dentures and was "gumming her food." Yet this information apparently never reached nursing staff responsible for care planning.
Employee E7 acknowledged there was no care plan addressing the resident's preference for not wearing dentures. There was also no plan for what staff termed "non-compliance related to wearing dentures."
The resident's situation illustrates how communication breakdowns between departments can leave vulnerable patients without proper care. Her occupational therapist made specific recommendations for neck exercises that could help prevent further spinal cord damage. Her speech therapist documented swallowing concerns related to eating without dentures.
But nursing staff — responsible for coordinating overall care — failed to translate these professional assessments into actionable care plans.
Federal regulations require nursing homes to develop comprehensive, person-centered care plans that address all resident needs with measurable actions and timetables. The facility's failure to plan for either the cervical exercises or dental issues violated these requirements.
The inspection found the facility's systemic problems extended beyond this single resident. Staff interviews revealed the facility was still developing basic programs that should have been operational, like restorative nursing services.
For the resident with spinal cord compression, the consequences of these gaps were immediate. She went nearly three months without the neck exercises her therapist recommended, potentially allowing her condition to deteriorate. She continued eating without properly fitting dentures, affecting her nutrition and dignity.
The woman's case demonstrates how administrative failures in nursing homes can directly impact residents' daily lives, leaving them without treatments specifically prescribed for their conditions while staff remain unaware of their ongoing struggles.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harborview Rehabilitation and Care Center At Lansd from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HARBORVIEW REHABILITATION AND CARE CENTER AT LANSD in LANSDALE, PA was cited for violations during a health inspection on August 21, 2025.
Her occupational therapist discharged her May 29 with specific recommendations for cervical range of motion exercises.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.