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Complaint Investigation

Complete Care At Harston Hall Llc

Inspection Date: September 17, 2025
Total Violations 2
Facility ID 395791
Location FLOURTOWN, PA
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Inspection Findings

F-Tag F0557

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Based on review of clinical records, observations, review of facility policy and interviews with residents, it was determined that the facility failed to ensure a resident was treated with dignity and respect during wound care for one of 12 residents reviewed (Resident Resident R1). Findings include: Review of Facility policy titled Clean dressing change, date implemented September 1, 2024, under Policy explanation and Compliance Guidelines, step 1 states Explain the procedure to the resident and screen for privacy. Review of Resident Resident R1's clinical record revealed resident was admitted to facility on August 13, 2025, with the diagnosis of Sepsis (infection in the blood stream), Paraplegia (paralysis on the lower half of the body), and Pressure Ulcer of Left Buttocks. Review of Resident Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) dated September 11, 2025, revealed that the resident has a BIMS (Brief interview for Mental Status) score of 15 indicating that resident cognitively intact.

Observation of Resident Resident R1's wound care with Employee E4, Licensed Practical Nurse on September 17, 2025, at 12:30pm revealed resident left with exposed buttocks after perineal care, for approximately 2 minutes, while staff prepared for dressing change. Observed multiple unnamed staff members entering and exiting room without introduction or providing the resident with privacy.Interview with Resident Resident R1 on September 17, 2025 at 12:45pm, revealed that this experience happens often when care is being provided and it makes him feel very uncomfortable. People come and go while I am getting care, I don't know who

they are, they do not introduce themselves, sometimes it someone dropping off a tray, other times it is housekeeping. It's uncomfortable when I am exposed and have no privacy and it doesn't seem like anyone cares. 28 Pa. Code: 201.18(b)(2) Management.28 Pa. Code: 201.29(j) Resident's rights.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Harston Hall LLC

350 Haws Lane Flourtown, PA 19031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited COMPLETE CARE AT HARSTON HALL LLC in FLOURTOWN, PA for a deficiency under regulatory tag F-F0610 during a complaint investigation conducted on 2025-09-17.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Respond appropriately to all alleged violations.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of COMPLETE CARE AT HARSTON HALL LLC.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-10.

📋 Inspection Summary

COMPLETE CARE AT HARSTON HALL LLC in FLOURTOWN, PA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FLOURTOWN, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COMPLETE CARE AT HARSTON HALL LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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