Complete Care at Harston Hall: Abuse Probe Failure - PA
She soiled herself shortly after.
When the aide came back and found what had happened, she looked at the resident and said, "This is just a mess," in what the resident's family described as a mean tone. The aide was forceful while changing her. The resident, who was fully cognitively intact, told her family she felt hurt and embarrassed.
That was the evening of August 26, 2025, at Complete Care at Harston Hall in Flourtown, Pennsylvania. The resident's daughter wrote a letter to the facility the same day, attached it to a formal grievance form, and asked a direct question: what will the consequence be for this behavior?
Three weeks later, federal inspectors arrived. There was no investigation.
The family's letter was specific and detailed. It described the time of the incident, roughly 8:50 p.m. It named what the aide said and how she said it. It described the physical handling as forceful. It asked for an apology and assurance that the behavior would not happen again. The family wrote that they needed to know their mother was safe.
The facility identified the aide, a certified nursing assistant listed in inspection records as Employee E5. Two days after the grievance was filed, on August 28, the aide received education on customer service and perineal care.
That was the extent of the response.
The facility's own abuse and neglect policy, implemented September 1, 2025, six days after the incident, states that an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation occurs. The policy lays out specific written procedures: identify staff responsible for the investigation, interview the alleged victim, interview the alleged perpetrator, interview witnesses, interview anyone else with knowledge of what happened, and document everything completely.
None of that happened. When inspectors reviewed the grievance file on September 17, there was no documented evidence of any investigation. The Director of Nursing, identified in inspection records as Employee E2, confirmed it in an interview. No investigation had been completed.
The resident is identified in inspection records as Resident R2. She was admitted to the facility with a diagnosis of end-stage renal disease. Her cognitive assessment, conducted on August 20, 2025, six days before the incident, gave her a score of 15 on the Brief Interview for Mental Status, the highest possible score, indicating she was fully cognitively intact. She knew exactly what had happened to her. She called her daughter from her room that evening, upset, and described it herself.
What the family described in their letter maps directly onto the facility's own definitions of what constitutes mistreatment. The policy defines verbal abuse as the use of oral communication that willfully includes disparaging and derogatory terms to residents, regardless of their ability to comprehend. It defines mental abuse to include humiliation and harassment. It defines mistreatment as inappropriate treatment of a resident.
An aide telling a resident that her soiled condition is "just a mess" in a mean tone, after refusing to help her reach the bathroom in the first place, falls within the plain language of those definitions. The facility's own policy required an immediate investigation. The family filed a formal grievance the same night it happened.
The facility gave the aide a training session.
There is a meaningful difference between responding to a complaint and investigating one. A training session on customer service does not determine whether abuse occurred. It does not produce a finding. It does not result in documentation that protects the next resident who shares a hallway with that aide. It does not answer the family's question about consequences.
The inspection report covers one resident out of twelve reviewed during the complaint inspection. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework inspectors apply. It does not mean what happened to this resident was minor.
She was a woman with a serious illness, dependent on staff for basic physical assistance, who asked for help getting to the bathroom and was refused. She was then handled roughly during a humiliating moment. She was cognitively intact throughout. She understood what was being said to her and how it was being said. She called her daughter in distress.
Her family wrote a careful, restrained letter. They did not demand termination. They asked for an apology. They asked for assurance. They asked what the consequence would be. They signed it "The family of," followed by their mother's name, which inspection records redact.
They filed that letter on August 26. Inspectors arrived September 17. In the twenty-two days between those two dates, the Director of Nursing confirmed to inspectors that no documented investigation had been completed.
The facility's abuse policy had been implemented on September 1, five days after the incident. Whether the absence of a prior policy contributed to the failure to investigate is not addressed in the inspection report. What the report does address is straightforward: the policy existed by the time inspectors arrived, it required an immediate investigation, and no investigation had been done.
The aide received education on customer service.
Facilities are required under Pennsylvania code to protect resident rights and to fulfill the responsibilities that come with licensure. Those obligations include taking a resident's report of mistreatment seriously enough to actually investigate it, to interview the people involved, to make a finding, and to document what was found. The grievance process is not a substitute for that. Routing a complaint through a customer service training does not constitute an abuse investigation.
The family's letter ended with a sentence that the inspection report quotes directly: "We need to know that she is safe and cared for while in this facility."
As of September 17, 2025, they still did not have an answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Harston Hall LLC from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
COMPLETE CARE AT HARSTON HALL LLC in FLOURTOWN, PA was cited for abuse-related violations during a health inspection on September 17, 2025.
She soiled herself shortly after.
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.