Inspection Reports for
Harmony at West Shore
1910 Technology Pkwy, Mechanicsburg, PA 17050, United States, PA, 17050
Back to Facility Profile36 Reports
Inspection Report — May 21, 2026
Renewal
Date: May 21, 2026
Visit Reason
The inspection was conducted as a full, unannounced renewal and complaint investigation of the facility.
Findings
The inspection identified multiple deficiencies including failure to provide requested resident records, breaches in record confidentiality, inadequate assistance with activities of daily living, improper storage and labeling of medications, failure to follow prescriber's orders, sanitary condition issues, and deficiencies in resident assessments and support plans. Plans of correction were accepted or directed with completion dates mostly in July and August 2026.
Citations (23)
Regulation 2600.5.a: The facility failed to provide requested resident records including medication orders, pharmacy receipts, and progress notes for Resident #1.
Regulation 2600.17: Confidential resident information was left unlocked and accessible at the nurse's station and receptionist desk, exposing sensitive data for multiple residents.
Regulation 2600.23.a: The facility lacked documentation of Resident #1's medical appointments and medication orders, hindering proper assistance with healthcare management.
Regulation 2600.82.a: Poisonous materials were stored in unlabeled or improperly labeled containers in the laundry and janitor's closet.
Regulation 2600.85.a: Sanitary conditions were not maintained, including mold and dust on kitchen ceiling tiles and feces around Resident #1's toilet bowl.
Regulation 2600.85.d: Trash receptacles in the kitchen were uncovered or had broken lids, allowing potential contamination.
Regulation 2600.88.a: Floors in the Memory Care Unit had sticky residue creating a fall hazard for residents with limited mobility.
Regulation 2600.95: A thermostat in Resident #6's bedroom lacked a cover, exposing wiring and creating a safety hazard.
Regulation 2600.132.d: Fire drill evacuation time exceeded the maximum safe time of 15 minutes, taking over 24 minutes.
Regulation 2600.141.b.1: Resident #10's medical evaluation did not indicate ability to self-administer medication.
Regulation 2600.162.c: Menus for the current and following week were not posted as required.
Regulation 2600.171.b: Staff Member D transported residents without completing required new hire direct care training.
Regulation 2600.183.b: Prescription and OTC medications were found unlocked and unattended in Resident #1 and #11's rooms.
Regulation 2600.183.e: Medications were not stored properly; loose pills and damaged blister packs were found in medication carts.
Regulation 2600.184.a: Pharmacy labels for several residents' medications did not include correct dosage instructions or sliding scale protocols.
Regulation 2600.185.a: Blood glucose readings documented on MARs did not match glucometer readings for Residents #1 and #11.
Regulation 2600.187.a: Resident #1's medication record lacked diagnosis or purpose for multiple medications and omitted a prescribed medication.
Regulation 2600.187.d: The facility failed to follow prescriber's orders for blood sugar checks, medication holds, and insulin administration for Residents #8, #10, and #11.
Regulation 2600.225.a: Resident initial assessments did not accurately reflect sensory and mobility needs for Residents #1 and #6.
Regulation 2600.225.c: Resident #6's additional assessment was not updated to reflect behavioral needs and incidents; Resident #11's assessments were outdated regarding mobility and medication self-administration.
Regulation 2600.227.d: Resident support plans did not accurately document required assistance with eating and writing for Residents #1 and #11.
Regulation 2600.231.b: Resident #9's medical evaluation did not document the need for care in a secured dementia care unit.
Regulation 2600.233.c: Directions for operating Secure Dementia Care Unit locking devices were not posted near the devices.
Report Facts
Residents Served: 94
Residents Served in Secured Dementia Care Unit: 30
Current Hospice Residents: 8
Residents Age 60 or Older: 94
Residents with Mobility Need: 48
Residents with Physical Disability: 2
Evacuation Time: 24.23
Maximum Safe Evacuation Time: 15
Medication Administration Record Audit Duration: 3
Fire Drill Re-education Completion Date: 2026
Notice — Apr 28, 2026
Date: Apr 28, 2026
Visit Reason
The document serves to notify Harmony at Hershey that a waiver request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted due to education obtained outside the United States.
Findings
The waiver is granted under specific conditions including documentation of education and training to be maintained and made available upon request. The Department will review this waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Apr 7, 2026
Date: Apr 7, 2026
Visit Reason
The document serves as a waiver approval for direct care staff employed at Harmony at Hershey who received their education outside the United States, exempting them from the requirement to have a U.S. high school diploma or GED under specific conditions.
Findings
The waiver is granted under the authority of 55 Pa.Code § 2600.19 with conditions including documentation of education and training to be maintained and made available upon request. The Department will review this waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jan 21, 2026
Complaint Investigation
Date: Jan 21, 2026
Visit Reason
The inspection was conducted as a complaint investigation following allegations of abuse and failure to report incidents at the facility.
Complaint Details
The complaint investigation was substantiated with findings of unreported abuse, neglect, and failure to report incidents to the Department and local agencies. The facility had open cases with the Area Agency on Aging but failed to report certain incidents themselves.
Findings
The facility was found to have multiple violations including failure to report suspected abuse and incidents to the appropriate authorities, neglect in following prescriber's orders, incomplete resident assessments, and inadequate documentation of medical care needs. The submitted plan of correction was accepted and fully implemented by April 15, 2026.
Citations (7)
2600.15.a The residence failed to immediately report suspected abuse involving residents barricading doors and preventing medication administration to the local area agency on aging.
2600.16.c The home did not report multiple incidents, including falls and missed medications, to the Department’s personal care home regional office within 24 hours as required.
2600.42.b Residents were neglected and verbally abused as staff were blocked from administering medications and incidents were not properly assessed or documented.
2600.142.a The home failed to assist a resident in securing medical care and did not document severe protein malnutrition, assistance needed with eating, or walker use after hospital discharge.
2600.187.d Routine medications were not administered to a resident on multiple dates and times as prescribed.
2600.225.a An initial written assessment was not completed within 15 days of admission for a resident.
2600.225.c The home did not complete an additional assessment or develop a support plan after a resident’s significant change in condition.
Report Facts
Residents Served: 81
Residents Served in Dementia Care Unit: 26
Current Hospice Residents: 5
Inspection Report — Sep 30, 2025
Follow-Up
Date: Sep 30, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple repeated violations including unsecured resident records, unsigned resident contracts, missing signed statements of resident rights, improperly installed resident enabler bars, improper storage of poisonous materials, uncovered trash receptacles, inoperable bedside lamps, improper refrigerator/freezer temperatures, failure to evacuate during fire drills, incomplete first aid kits in transport vehicles, and missed medication administrations. Corrective actions and training were implemented with ongoing audits planned.
Citations (13)
Resident records were unsecured and accessible on an unattended nurse’s station desk.
Resident-home contracts were not signed by the residents as required.
Resident records lacked signed statements acknowledging receipt of resident rights and complaint procedures.
Resident enabler bars were improperly installed and had uncovered openings exceeding regulatory limits.
An unlabeled spray bottle of unknown substance was found in the Secure Dementia Care Unit (SDCU).
Poisonous materials were stored unlocked and unattended in the SDCU, including bottles with warning labels.
A large trash can in the SDCU kitchen was uncovered and half full, posing a risk of insect and rodent penetration.
Trash outside the home was not properly contained; gates to dumpster area were open with trash and debris around.
Some resident bedrooms in the SDCU lacked operable lamps or lighting that could be turned on/off at bedside.
A freezer in the SDCU kitchen contained ice cream at 22°F, exceeding the required temperature of 40°F or below.
During a fire drill, one resident refused to evacuate to the designated meeting place away from the building.
First aid kits in the van and bus used for resident transport were missing tweezers and a thermometer.
A resident was not administered prescribed medications on multiple dates and times as ordered.
Report Facts
Residents Served: 71
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 1
Residents Age 60 or Older: 72
Residents with Mobility Need: 34
Inspection Report — Jan 15, 2025
Complaint Investigation
Date: Jan 15, 2025
Visit Reason
The inspection was conducted due to a complaint and incident involving resident abuse and other regulatory concerns at the facility.
Complaint Details
The visit was complaint-related due to allegations of resident abuse, failure to report abuse, medication errors, and other regulatory violations. The complaint was substantiated with multiple violations found during the inspection.
Findings
The inspection identified multiple violations including failure to provide immediate access to records, failure to report suspected resident abuse, medication errors, confidentiality breaches, resident abuse incidents, privacy violations, use of prohibited portable space heaters, incomplete resident assessments, failure to follow prescriber's orders, and deficiencies in support plan documentation and signatures.
Citations (12)
Failure to provide immediate access to resident and staff records upon request by Department agents.
Failure to immediately report suspected resident abuse incidents to the Area Agency on Aging (AAA).
Failure to report medication errors to the Department in a timely manner.
Resident records were left unsecured and accessible on an unlocked laptop screen.
Resident abuse incidents including physical abuse and improper restraint techniques were witnessed and documented.
Violation of resident privacy rights due to unauthorized video recording of care.
Use of prohibited portable space heater in a resident's room.
Resident was not properly assessed for self-administration of medications as required.
Failure to follow prescriber's medication orders for residents.
Incomplete or missing annual assessments for residents.
Support plan did not document resident's medical dietary needs correctly.
Support plans lacked signatures from residents or responsible parties indicating participation.
Report Facts
Residents Served: 52
Residents Served in Dementia Care Unit: 16
Current Hospice Residents: 3
Residents Age 60 or Older: 52
Residents with Mobility Need: 29
Residents with Physical Disability: 1
Total Daily Staff: 81
Waking Staff: 61
Inspection Report — Jul 2, 2024
Complaint Investigation
Date: Jul 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation with provisional and incident reasons, including follow-up on a plan of correction submission.
Complaint Details
The inspection was complaint-driven with provisional and incident reasons. Multiple repeated violations were noted, including failure to report abuse, medication errors, and confidentiality breaches.
Findings
The inspection identified multiple deficiencies including delayed access to resident and staff records, failure to timely report and supervise abuse incidents, medication administration errors, unsecured poisonous materials, environmental hazards, incomplete medical evaluations, and confidentiality breaches. Plans of correction were accepted or directed with specified completion dates.
Citations (32)
Delayed access to resident and staff records upon Department request.
Failure to immediately report suspected resident abuse and incomplete abuse reporting forms.
Failure to develop and implement a supervision plan or suspend staff involved in abuse allegations.
Failure to report abuse incidents to the Department within 24 hours.
Resident treated without dignity and respect; inappropriate staff-resident interactions.
Criminal background checks not obtained timely for certain staff members.
Poisonous materials not locked and accessible to residents unable to safely use them.
Uncovered trash receptacles in kitchens and bathrooms.
Floor hazard due to a 3 inch divot under carpet posing tripping risk.
Emergency telephone numbers not posted by telephones with outside lines.
Furniture and equipment not in good repair; fire door lock systems exposed or damaged.
Resident bedrooms lacked operable lamps or lighting within reach at bedside.
Egress routes obstructed by furniture and equipment.
Emergency evacuation diagrams incomplete, missing pull stations and fire extinguisher locations.
Initial medical evaluations incomplete or missing required information such as allergies and diagnoses.
Annual medical evaluations not completed timely.
Resident special dietary needs not met or documented accurately.
Medications and syringes not kept locked and accessible only to authorized staff.
Discontinued or expired medications present in medication carts and resident rooms.
Prescription medication containers not properly labeled with required information.
Medication and medical equipment storage procedures inadequate, resulting in medication unavailability and inaccurate documentation.
Prescription medications lacked current prescriber orders.
Prescription medications used by residents other than those prescribed.
Medication records lacked accurate route of administration and special precautions.
Refusals of medications not documented or reported to prescribers as required.
Failure to follow prescriber's medication orders, including incorrect dosages and missed doses.
Resident assessments incomplete or inaccurate, missing key needs such as mobility or dietary requirements.
Resident support plans lacked documentation on how needs will be met and lacked required signatures.
Resident support plans not accessible to direct care staff at all times.
Residents not assessed annually for continuing need for secured dementia care unit.
Directions for operating key-locking devices not conspicuously posted near exit doors.
Resident records not maintained confidentially; records left unsecured and accessible to unauthorized persons.
Report Facts
Residents Served: 60
Residents Served in Secure Dementia Care Unit: 16
Staffing Hours - Total Daily Staff: 86
Staffing Hours - Waking Staff: 65
Deficiencies Cited: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aleanah Cruz | Dietary Aide | Named in relation to criminal background check deficiency. |
| Ava Aquallo | Dietary Aide | Named in relation to criminal background check deficiency. |
| Stephanie Wolfley | Acting Healthcare Director | Named in relation to leadership and training on medication and regulatory compliance. |
| Robert Musser | Executive Director | Named in relation to leadership, training, and oversight of compliance. |
Inspection Report — Apr 17, 2024
Follow-Up
Date: Apr 17, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 04/17/2024 to review the submitted plan of correction related to prior deficiencies and to verify compliance.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Deficiencies related to medication self-administration assessment, prescription currency, and medication storage were addressed with training, audits, and removal of improper medications.
Citations (3)
Resident self-administers prescribed medication without assessment by a qualified healthcare provider regarding ability to self-administer.
Discontinued medication was found in the home's medication cart after resident moved from secured dementia care unit to personal care.
Loose pills were observed in multiple medication carts in the facility, indicating improper medication storage.
Report Facts
Residents Served: 78
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 3
Residents with Mobility Need: 36
Residents with Physical Disability: 1
Total Daily Staff: 114
Waking Staff: 86
Inspection Report — Dec 20, 2023
Complaint Investigation
Date: Dec 20, 2023
Visit Reason
The inspection was conducted due to complaints and incidents reported at the facility, including a follow-up on prior violations and interim exit conference.
Complaint Details
The inspection was complaint-driven due to incidents of resident abuse and other regulatory concerns. The abuse allegations were substantiated with multiple physical altercations documented between residents, resulting in injuries.
Findings
Multiple violations were found including abuse incidents, failure to report incidents timely, medication management issues, staff training deficiencies, sanitary condition problems, and record-keeping errors. Several violations were repeated from prior inspections. Plans of correction were accepted or directed with proposed completion dates.
Citations (20)
Failure to report an incident of resident hitting another resident within 24 hours.
Resident abuse incidents involving physical altercations between residents.
No staff certified in first aid and CPR present during night shift.
New staff did not receive required fire safety orientation on first day.
Direct care staff did not complete required orientation within 40 hours.
Poisonous materials were unlocked and accessible to residents incapable of safe use.
Written emergency procedures not reviewed and submitted annually to local emergency management agency.
Fire drill records incomplete, missing evacuation times and participant counts.
Residents unable to fully evacuate during fire drill and evacuation time exceeded limit.
Initial medical evaluation for a resident was completed after admission date.
Expired medications found in medication storage.
Loose pills found in medication carts.
Medication container not labeled with date opened.
Discrepancies between glucometer readings and medication administration record.
Controlled substance administration not recorded with date, time, and staff initials.
Medications not administered as prescribed due to unavailability.
Insulin administered despite blood sugar levels below prescribed threshold.
Resident assessments and support plans not current or lacking required documentation.
Records containing resident names were posted publicly, violating confidentiality.
Directions for operating key-locking devices not posted near exit door.
Report Facts
Residents Served: 72
Residents Served in Secure Dementia Care Unit: 22
Staffing Hours - Total Daily Staff: 102
Staffing Hours - Waking Staff: 77
Deficiencies Cited: 4
Fine per Violation per Day: 5
Total Fine per Violation: 385
Residents Served: 77
Residents Served in Secure Dementia Care Unit: 23
Staffing Hours - Total Daily Staff: 123
Staffing Hours - Waking Staff: 92
Inspection Report — Oct 17, 2023
Complaint Investigation
Date: Oct 17, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility on 10/17/2023.
Complaint Details
The visit was complaint-related and substantiation is implied by the findings of abuse and privacy violations.
Findings
The report found multiple violations including failure to immediately report suspected resident abuse, an incident of resident-to-resident abuse resulting in injury, and a privacy violation involving unauthorized photographing of a resident. Plans of correction were accepted and implemented.
Citations (3)
Failure to immediately report suspected resident-to-resident abuse to the local Area Agency on Aging.
Resident-to-resident abuse where Resident 2 hit Resident 1 with a wooden block causing injury requiring emergency room transfer.
Violation of resident privacy by photographing a resident on a staff member's private cell phone and circulating the photo among staff.
Report Facts
Residents Served: 84
Residents Served in Secured Dementia Care Unit: 24
Current Hospice Residents: 9
Residents Age 60 or Older: 84
Residents with Mobility Need: 60
Inspection Report — Jul 20, 2023
Complaint Investigation
Date: Jul 20, 2023
Visit Reason
The inspection was conducted due to complaints and incidents reported at the facility, including a serious resident injury and multiple regulatory concerns.
Complaint Details
The inspection was complaint-related and incident-related. The incident involved Resident 1 eloping from the secured courtyard, sustaining multiple injuries including heat stroke and burns, and delayed discovery by staff. The incident report was incomplete and inaccurate. Abuse and neglect training and audits were directed.
Findings
The inspection found multiple deficiencies including failure to secure poisonous materials, unsanitary conditions, medication management issues, incomplete support plans, and inadequate incident reporting. A serious incident involving a resident eloping and sustaining injuries was documented with incomplete reporting.
Citations (22)
2600.51 Criminal Background Check: Staff Member A did not have a criminal background check completed until 3/9/23.
2600.63a First Aid/CPR Training: The home lacked sufficient staff certified in CPR and First Aid during multiple shifts.
2600.65d Initial Direct Care Training: Direct Care Staff Member C provided unsupervised ADL services without completing required training.
2600.81b Resident Personal Equipment: Uncovered enabler bars with openings posing entrapment risks were observed on residents' beds.
2600.85d Trash Receptacles: Trash cans in the kitchen had broken lids exposing trash, allowing insect and rodent penetration.
2600.88a Surfaces: Fire damage with protruding nails and other hazards such as broken glass, holes in ceilings, and stained carpets were found.
2600.105g Lint Removal and Duct Cleaning: Lint traps for dryers were not cleaned regularly; last cleaned 6/10/21 and lint accumulation found during inspection.
2600.109b Rabies Vaccination: Pets present lacked current rabies vaccination certificates.
2600.183b Meds and Syringes Locked: Medications and syringes were found unlocked and accessible in resident rooms.
2600.183e Storing Medications: Several prescribed medications were missing from the home at inspection.
2600.187d Follow Prescriber's Orders: Resident 8 was not administered prescribed insulin on multiple dates.
2600.224a Preadmission Screen Form: Resident preadmission screening forms were incomplete or not timely.
2600.227c Support Plan Revision: Resident 2's support plan was not revised timely to reflect memory care needs.
2600.251c Standardized Forms: Resident RASPs were not completed on the Department’s current standardized form and lacked required language.
2600.82c Locking Poisonous Materials: Poisonous materials were unlocked and accessible to residents unable to safely use or avoid them.
2600.85a Sanitary Conditions: Strong urine odors, liquid substances on floors, soiled linens, and stained CPAP masks were observed.
2600.254a Records Discharge/Active: Resident records were found unlocked, unattended, and accessible.
2600.187a Medication Record: Resident 1 had medication in possession not listed on the Medication Administration Record.
2600.101j3 Bed/Linens/Pillows/Blankets: Resident beds had linens with dried brown and white spots, indicating unclean conditions.
2600.88a Surfaces: Carpeting with low spots creating tripping hazards, cracks in drywall, bird nests obstructing dryer vents, and stained carpets were observed.
2600.42b Abuse: Resident 1 eloped from the secured courtyard, was found hours later with multiple injuries including heat stroke and burns; incident report was inaccurate and incomplete.
2600.234b Support Plan Needs Elements: Resident 1's support plan did not include documented manic episodes or required services to address behaviors.
Report Facts
Residents Served: 93
Residents Served in Secured Dementia Care Unit: 27
Residents Served: 100
Residents Served in Secured Dementia Care Unit: 29
Residents Served in Secured Dementia Care Unit: 28
Residents Served in Secured Dementia Care Unit: 32
Residents Served: 73
Total Daily Staff: 125
Total Daily Staff: 134
Total Daily Staff: 111
Inspection Report — May 30, 2023
Complaint Investigation
Date: May 30, 2023
Visit Reason
The inspection was conducted as a complaint investigation with announced partial inspections on May 30-31, 2023, to review compliance with licensing regulations.
Complaint Details
The inspection was complaint-driven as stated under Inspection Information with Reason: Complaint. The exit conference was held on 05/31/2023. No substantiation status is explicitly stated.
Findings
Multiple violations were found including lack of required annual staff training, unsafe resident equipment posing entrapment risks, unsecured poisonous materials accessible to residents, unsanitary conditions, damaged surfaces posing hazards, medication management issues, and unsecured resident records. Plans of correction were accepted but many were not implemented as of the follow-up date.
Citations (10)
Direct care staff did not receive required annual training on multiple topics including medication self-administration and infection control.
Ancillary and direct care staff did not receive annual training on fire safety, emergency preparedness, resident rights, and other topics.
Uncovered enabler bars on resident beds posed entrapment risks.
Poisonous materials were found unlocked and accessible to residents unable to safely use or avoid them.
Sanitary conditions were not maintained; CPAP mask discoloration and soiled undergarments found in resident rooms.
Floors and walls had hazards including low spots under carpet, cracks in drywall, stained carpet, and bird nests obstructing dryer vents.
Resident bed linens were soiled with dried spots.
Prescription medications were found unlocked and unattended in resident rooms.
Medication record did not list a medication found in resident's possession.
Resident records were found unlocked and accessible in nurse's station.
Report Facts
Residents Served: 100
Residents in Secured Dementia Care Unit: 28
Residents in Hospice: 10
Total Daily Staff: 133
Waking Staff: 100
Inspection Report — Apr 26, 2023
Complaint Investigation
Date: Apr 26, 2023
Visit Reason
The inspection was a complaint investigation conducted on April 26, 2023, as part of licensing inspections triggered by complaints at Harmony at West Shore.
Complaint Details
The inspection was conducted as a complaint investigation with an interim exit conference on April 26, 2023.
Findings
Multiple violations were found including unsecured poisonous materials accessible to residents, unsanitary conditions with strong urine odors, tripping hazards due to loose carpet, broken glass in resident rooms, stained carpets, lint accumulation in dryers, and unsecured resident records on an unlocked laptop.
Citations (5)
Poisonous materials were unlocked and accessible to residents unable to safely use or avoid them in the secured dementia care unit and resident rooms.
Strong urine smell and liquid substances were present in the secured dementia care unit bathrooms and hallways.
Sticky floor in the public bathroom, loose carpet creating a tripping hazard, broken lightbulb glass on floor, hole in ceiling, stained carpet, and liquid substance on floor posing slipping hazard.
Accumulation of lint in the lint trap of clothes dryers, posing fire hazard.
Resident records were visible and accessible on an unlocked laptop on top of the medication cart.
Report Facts
Residents Served: 100
Residents in Secured Dementia Care Unit: 29
Current Hospice Residents: 10
Staffing Hours - Total Daily Staff: 134
Staffing Hours - Waking Staff: 101
Residents with Mobility Need: 34
Residents with Physical Disability: 1
Resident Records Visible on Laptop: 16
Lint Accumulation: 0.25
Inspection Report — Mar 8, 2023
Renewal
Date: Mar 8, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the Harmony at West Shore facility.
Findings
Multiple violations were found related to criminal background checks, staff training, resident safety, medication management, and documentation. Plans of correction were submitted and partially implemented, with some deficiencies not yet fully corrected as of the report date.
Citations (15)
Staff Member A did not have a criminal background check completed until 3/9/23.
Insufficient number of staff certified in CPR and First Aid present during certain shifts.
Direct Care Staff Member C provided unsupervised ADL services without completing initial direct care training.
Uncovered enabler bars on Resident 1's and Resident 2's beds posed potential hazard.
Trash cans in kitchen were filled with trash and had broken lids exposing trash.
Fire damage on dining room patio wall with protruding nails presenting hazard.
Lint traps for dryers were last cleaned on 6/10/21, not regularly maintained.
Resident 3's and Resident 4's pets lacked current rabies vaccination certificates.
Medications and syringes were found unlocked and accessible to residents.
Insulin pens were not labeled with date opened as per manufacturer instructions.
Medications for Residents 8, 9, 10, and 11 were missing from the home.
Resident 8 was not administered prescribed insulin on multiple dates.
Resident 12's preadmission screening form lacked determination that needs could be met; Resident 13's form was completed after admission.
Resident 2's support plan was not revised timely to reflect changes in needs.
Residents 1, 2, and 6 through 13 had RASPs not completed on the Department’s standardized form and missing required language.
Report Facts
Residents Served: 73
Residents in Secured Dementia Care Unit: 32
Current Hospice Residents: 7
Total Daily Staff: 111
Waking Staff: 83
Residents 60 Years or Older: 105
Residents with Mobility Need: 38
Staff Certified in CPR and First Aid Required per Shift: 3
Staff Certified in CPR and First Aid Present: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed the licensing letter regarding provisional license. |
| Executive Director | Named in multiple findings related to audits, corrections, and re-education. | |
| Healthcare Director | Named in findings related to medication management, staff training, and audits. | |
| Maintenance Director | Named in findings related to maintenance corrections and inspections. | |
| Dining Services Director | Named in findings related to kitchen trash can corrections. |
Inspection Report — Jun 2, 2022
Original Licensing
Date: Jun 2, 2022
Visit Reason
The inspection was conducted as part of the licensing inspections on March 8 and 9, 2022 and June 2, 2022, to evaluate compliance with Pennsylvania Personal Care Homes regulations and to issue a regular license.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes, and no deficiencies were found during the inspection.
Report Facts
Residents Served: 84
Residents in Secured Dementia Care Unit: 30
Current Hospice Residents: 14
Residents with Mobility Need: 32
Residents Age 60 or Older: 84
Residents with Physical Disability: 1
Inspection Report — Jun 2, 2022
Renewal
Date: Jun 2, 2022
Visit Reason
The inspection visits on March 8 and 9, 2022 and June 2, 2022 were conducted as part of the licensing inspections for the facility to ensure compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with the applicable regulations after the inspections and corrections made. Therefore, a regular license was issued.
Inspection Report — Mar 8, 2022
Renewal
Date: Mar 8, 2022
Visit Reason
The inspection was conducted as a renewal, complaint, and provisional inspection to assess compliance with licensing requirements and regulations.
Findings
The facility was found to be in compliance with Personal Care Home regulations after corrections were made. Several deficiencies were identified and corrected, including posting the current inspection report, compliance with health and safety laws, trash management, emergency telephone numbers, fire safety inspection, smoking area guidelines, menus posting, preadmission screening, support plans, medication storage, and documentation.
Citations (12)
The home's current inspection report, dated 07/29/21, was not posted in a conspicuous and public place in the home.
The home's boilers were last inspected on 10/23/19, with an expiration date of 10/23/21.
The lids on the right and left dumpsters were left open exposing the trash inside.
There are no emergency telephone numbers that included the nearest hospital and fire department on or by the telephones located in Resident Bedroom 414 and the nurses' station on second floor.
The last fire drill observed by a fire safety expert was conducted on 01/06/22. The home did not complete a fire safety inspection and supervised drill in December 2021.
The home does not permit smoking anywhere on the property. However, cigarette butts and two lighters were found in the home's back patio/concrete area.
The home's menu for the current and future weeks were not posted.
Resident 2 was admitted to the home on a redacted date in 2021; however, the resident's preadmission screening form was not completed until a later redacted date in 2021.
The assessments for Resident #3 and #4 do not indicate that either resident has a need for an enabler bar. The enabler bars were discovered on 03/09/22.
Prescription medications, OTC medications, CAM and syringes were found unlocked and stored in an area/container accessible in the resident's room. A small, peach-colored pill was found on the floor outside Resident Room #311.
A loose pill was found in the medication cart of the secured dementia care unit (SDCU).
Blood sugar readings documented on the medication administration record (MAR) for Resident 1 on multiple dates were incorrect or missing in the glucometer documentation.
Report Facts
Residents Served: 80
Secured Dementia Care Unit Residents Served: 26
Current Hospice Residents: 10
Residents Age 60 or Older: 80
Residents with Mobility Need: 30
Residents with Physical Disability: 2
Staffing Hours - Total Daily Staff: 110
Staffing Hours - Waking Staff: 83
Notice — Nov 18, 2021
Date: Nov 18, 2021
Visit Reason
This document acknowledges receipt of an appeal request concerning the Department's decision to revoke a regular license and issue a first provisional license for Harmony at West Shore.
Findings
The document does not contain inspection findings but confirms the forwarding of the appeal request to the Bureau of Hearings and Appeals and indicates that the appellant will be contacted about the hearing date and time.
Notice — Apr 30, 2021
Date: Apr 30, 2021
Visit Reason
The document serves as a renewal notice confirming receipt of the renewal application for the Personal Care Home and informing that a regular license is being issued. It also advises that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice confirming compliance and issuance of a regular license.
Report Facts
Inspection Report — Apr 27, 2021
Renewal
Date: Apr 27, 2021
Visit Reason
The inspection was conducted as part of a renewal licensing inspection with multiple visits between March and July 2021 to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to have multiple violations including medication errors, incomplete resident contracts, inadequate staff training, improper storage of medications and poisonous materials, and deficiencies in resident medical evaluations and support plans. A provisional license was issued due to these violations with required plans of correction and follow-up inspections.
Citations (32)
2600.16c Medication errors occurred when several residents did not receive prescribed morning medications on specified dates and these errors were not reported to the Department as required.
2600.25b The resident-home contract dated 11/11/2020 for Resident #1 was not signed by the resident.
2600.63a On 4/14/2021 and 4/16/2021, 65 residents were present but only one staff person was trained and certified in first aid and CPR, which is insufficient.
2600.65a Staff persons A, B, C, D, and G did not receive orientation on evacuation procedures, fire drills, smoke detectors, fire alarms, or emergency notification.
2600.65b Staff persons A, B, C, D, F, and G did not receive orientation training on mandatory reporting of abuse, neglect, or reportable incidents and conditions.
2600.65c Ancillary staff persons A, B, C, D, F, and G who perform ancillary duties did not have general orientation to their specific job functions.
2600.65d Direct care staff persons A and B provided unsupervised ADL services without completing required direct care training and competency testing.
2600.105g Lint was not removed from lint traps in laundry dryers, creating a fire hazard.
2600.141a Resident #9's medical evaluation dated 3/25/21 lacked information on blood pressure, temperature, pulse rate, body positioning, and date of completion.
2600.183b Prescription medications and syringes were not kept locked; a bottle of fish oil capsules and vial of Amoxicillin were accessible to Resident #10.
2600.185a Blood glucose levels were not recorded in the resident's glucometer for Resident #11, with inconsistent readings documented.
2600.186b A vial of Amoxicillin was found unsecured on Resident #10's apartment table; prescription was for another individual.
2600.187d Resident 10's medications were not given from 7/1/21 to 7/5/21 due to unavailability, including Vitamin D3, Folic Acid, and Cinacalcet.
2600.188b Medication errors were not reported to residents' physicians for Residents #2, #3, #4, #5, #6, #7, and #8 as required.
2600.225a Resident #15 was admitted without an initial assessment completed within 15 days of admission; Resident #6's assessment lacked need for bedrails documentation.
2600.225c Resident #2's additional assessment was not completed timely; previous assessment dated 6/6/19.
2600.227d Resident #6's support plan did not include protection from potential dangers of two one-half bedrails attached to the resident's bed.
2600.231b Resident #12's medical evaluation did not indicate diagnosis of Alzheimer's disease or dementia despite admission to secured dementia care unit.
2600.231c Resident #1's cognitive preadmission screening was not completed prior to admission to secured dementia care unit.
2600.231e Resident #1's admission lacked documentation that the designated person did not object to admission to secured dementia care unit.
2600.233c Directions for operating home's locking mechanism were not conspicuously posted near main doors to secured dementia care unit.
2600.254a Records of active and discharged residents were not secured and accessible; medication count sheets and incident reports were on top of medication cart.
2600.65a Staff Person B, hired 2021, did not receive orientation on evacuation procedures, fire drills, smoke detectors, fire alarms, or emergency notification.
2600.65b Staff persons A, B, C, D, E, and F hired in 2021 did not receive training on mandatory reporting of abuse, neglect, or reportable incidents.
2600.183b On 7/28/21, a 4-ounce tube of CVS Lidocaine pain relief roll-on was unlocked and accessible on Resident 4's bedroom kitchen counter.
2600.183e The blister pack for Resident 5's Oxycodone was torn and a tablet protruded through the foil backing.
2600.185a Resident 5's and 6's glucometers were programmed with incorrect dates and times.
2600.187a Residents 5, 7, and 8's medication administration records did not include doses of insulin administered or injection records.
2600.187d Resident 10's medications were not given from 7/1/21 through 7/5/21 due to unavailability, repeated violation.
2600.227h The support plan for Resident 9 was not signed by the resident nor marked for refusal or inability to sign.
2600.231c Resident 3's preadmission cognitive screening was not completed prior to admission to secured dementia care unit.
2600.234a Resident 3's initial support plan was not completed within 72 hours of admission to secured dementia care unit.
Report Facts
Residents present: 66
Residents served: 66
Residents served in secured dementia care unit: 23
Residents served hospice: 10
Staff present: 1
Inspection Report — Jan 15, 2021
Renewal
Date: Jan 15, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections on multiple dates in January 2021.
Findings
No regulatory citations were identified as a result of the inspection.
Inspection Report — Nov 9, 2020
Renewal
Date: Nov 9, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Oct 13, 2020
Complaint Investigation
Date: Oct 13, 2020
Visit Reason
The inspection was a complaint investigation conducted on 10/13/2020 to review compliance with regulations at Harmony at West Shore.
Complaint Details
The inspection was triggered by a complaint regarding improper restraint and medication administration issues. The complaint was substantiated based on findings of restraint and medication delays.
Findings
The inspection found that a resident was improperly restrained by being locked in the Secured Dementia Care Unit daily. There were also significant medication administration delays due to staffing shortages, failure to follow prescriber's orders, and missing conspicuous posting of keypad lock operation instructions in the dementia unit.
Citations (4)
42p - Restraints: Resident #1 was restrained by being locked in the Secured Dementia Care Unit daily from early August to October 7, 2020.
60a - Staff/Support Plan: The home was not routinely staffed to meet medication administration needs, causing delays in medication delivery on 10/11/2020 for Residents #2, #3, #4, and #5.
187d - Follow Prescriber's Orders: The home failed to administer medications at prescribed times on 10/11/2020 for Residents #2, #3, #4, and #5.
233c - Key-Locking Devices: Directions for operating the keypad locking mechanism were not conspicuously posted near exits of the Secure Dementia Care Unit.
Report Facts
Residents served: 70
Residents in Secured Dementia Care Unit: 16
Residents with mobility need: 16
Medication administration delays: 4
Medications not administered on time: 18
Inspection Report — Oct 1, 2020
Renewal
Date: Oct 1, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 10/01/2020 and 10/02/2020.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Jul 2, 2020
Date: Jul 2, 2020
Visit Reason
The inspection visits were conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing for licensing inspections of the facility Harmony at West Shore on multiple dates in July and August 2020.
Findings
No regulatory citations were identified as a result of these inspections.
Inspection Report — Jun 11, 2020
Routine
Date: Jun 11, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Feb 10, 2020
Renewal
Date: Feb 10, 2020
Visit Reason
The inspection was an unannounced renewal inspection of Harmony at West Shore conducted by the Pennsylvania Department of Human Services on February 10, 2020.
Findings
The facility was found to have deficiencies related to medication administration, storage procedures, and following prescriber's orders. A plan of correction was submitted and determined to be fully implemented as of the inspection date.
Citations (3)
185a - The home failed to implement procedures for safe storage and use of medical equipment, as blood sugar readings on residents' glucometers did not match medication administration records.
187b - Resident #2's medication packaging change was not documented in the home's electronic medication record, resulting in undocumented administrations from 2/1/20 to 2/10/20.
187d - Resident #3 was not administered prescribed Levothyroxine and Hydralazine on specified dates due to medication unavailability in the home.
Report Facts
Residents Served: 44
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 1
Residents Age 60 or Older: 44
Residents with Mobility Need: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samantha Sipe | Executive Director | Signed plan of correction and named as Administrator |
Notice — Jan 23, 2020
Date: Jan 23, 2020
Visit Reason
This document serves as a renewal approval for the Personal Care Home license for Harmony at West Shore and notifies the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Jul 31, 2019
Complaint Investigation
Date: Jul 31, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to alleged abuse and regulatory compliance at Harmony at West Shore.
Complaint Details
The complaint investigation was substantiated with findings that Staff Person A committed abuse and mistreatment of residents. Staff Person A was placed on immediate leave and subsequently released from employment. Staff received training on abuse, neglect, and resident rights. The facility implemented ongoing monitoring and corrective actions.
Findings
Multiple violations of 55 Pa.Code Ch. 2600 were found, including failure to immediately report suspected abuse, failure to treat residents with dignity and respect, incomplete educational records for staff, improper seclusion practices, and incomplete preadmission screening documentation. Corrective actions and staff training were implemented following the investigation.
Citations (6)
2600.15.a The home failed to immediately report suspected abuse of residents by Staff Person A to the local Area Agency on Aging within required timeframes.
2600.16.c The home did not report suspected abuse by Staff Person A to the Department within 24 hours of receipt of information.
2600.42.c Staff Person A did not treat Resident 3 with dignity or respect by grabbing, pushing, and yelling at the resident during an overnight shift in the secured dementia care unit.
2600.54.a The record of Staff Person A lacked educational information for secondary school education or a waiver from the Department.
2600.202 The home prohibited seclusion was violated when Staff Person A forcibly sat Resident 1 in a wheelchair, pushed him into an unoccupied room, and left him isolated without ability to exit.
2600.231.c Resident 4's written cognitive preadmission screening form was not completed in collaboration with a physician or geriatric assessment team within 72 hours prior to admission to the secured dementia care unit.
Report Facts
Residents Served: 29
Secured Dementia Care Unit Residents Served: 10
Hospice Current Residents: 2
Residents with Mobility Need: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amber Kuhn | Executive Director | Named as legal entity representative and involved in reporting and corrective actions. |
Inspection Report — Apr 22, 2019
Renewal
Date: Apr 22, 2019
Visit Reason
The inspection was an annual renewal inspection conducted by the Department’s Bureau of Human Services Licensing on April 22 and 23, 2019.
Findings
The inspection identified multiple violations of 55 Pa.Code Ch. 2600 related to Personal Care Homes, including issues with contract signatures, criminal background checks, medication administration training, fire safety orientation, medication storage, refrigerator temperatures, rabies vaccination for pets, resident rights education, and key-locking device signage. Plans of correction were submitted and partially implemented as of August 2019.
Citations (10)
2600.18: The influenza poster was located in the employee break room and was not accessible to residents and visitors.
2600.25(b): The resident-home contracts for Residents #1 and #2 were not signed by the resident.
2600.51: Staff file was unable to be located at time of inspection; correction implemented to ensure criminal background checks for new hires.
2600.65(a) and (b): Scheduled agency staff will complete orientation for fire safety, resident rights, emergency medical plan, OAPSA, and reportable incidents; audit showed agency staff no longer assigned to community.
2600.103f: Activity room freezer temperature was 6°F and no thermometer was in the refrigerator.
2600.109(b): The home lacked a current rabies vaccination certificate for Resident #3's cat.
2600.183(b): Medication administration training for Staff person A did not include the trainer's signature; the staff person scored 87 on the competency test, below the passing score of 90.
2600.190(a): Medications and syringes were not locked; an unattended cabinet was unlocked with an opened, unlabeled medication tube.
2600.191: The home did not have documentation that residents were educated on their right to refuse medication if they believed there was an error.
2600.233(c): Directions for operating the home's locking mechanism were not conspicuously posted near the Secure Dementia Care Unit door.
Report Facts
Residents Served: 27
Secured Dementia Care Unit Residents Served: 6
Hospice Current Residents: 1
Resident Age 60 or Older: 27
Residents with Mobility Need: 8
Residents with Physical Disability: 1
Resident Support Staff: 0
Total Daily Staff: 35
Waking Staff: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amber Kuhn | Executive Director | Named as administrator and signatory on plans of correction |
| Angela Alvarado | HCC | Implemented immediate correction for influenza poster placement |
| Casey Murphy | Implemented correction for criminal background check process | |
| Bambi Phillips | State Inspector | Noted immediate correction on activity room thermometer |
Notice — Apr 15, 2019
Date: Apr 15, 2019
Visit Reason
The document responds to a request for a waiver of specific Pennsylvania Code regulations related to initial and annual assessments and support plan development for the licensed personal care home Harmony at West Shore.
Findings
The Department determined that the waiver is not needed because the facility's own forms meet the regulatory requirements. The letter also reminds the facility of notification requirements when submitting waiver requests.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Implementation Manager | Signed the waiver response letter. |
Notice — Apr 5, 2019
Date: Apr 5, 2019
Visit Reason
The document serves to notify the facility of a new license issuance due to a recent name change from The Crossings at West Shore to Harmony at West Shore, with the license expiration date remaining unchanged.
Findings
No inspection findings or deficiencies are reported in this document. It is an administrative license update.
Report Facts
Inspection Report — Feb 19, 2019
Complaint Investigation
Date: Feb 19, 2019
Visit Reason
The inspection was conducted as a complaint investigation at The Crossings at West Shore Personal Care Home.
Complaint Details
The inspection was complaint-driven. The violation involved Resident #1 admitted on 6/7/18 with the support plan developed on 6/15/18, indicating a delay in compliance.
Findings
A violation was found related to the failure to develop, implement, and document a support plan within 72 hours of admission to the secured dementia care unit. The facility must ensure compliance with 55 Pa.Code Chapter 2600.
Citations (1)
55 Pa.Code §2600.234(a) requires a support plan to be developed, implemented, and documented within 72 hours of admission to the secured dementia care unit. Resident #1's initial support plan was delayed beyond the required timeframe.
Report Facts
Number of Residents Served: 23
Number of Residents Served in Secured Dementia Care Unit: 7
Notice — Jan 30, 2019
Date: Jan 30, 2019
Visit Reason
The document serves as a renewal notification and license issuance for The Crossings at West Shore Personal Care Home following receipt of the renewal application dated January 28, 2019.
Findings
The Department of Human Services confirms issuance of a regular license for the facility with a maximum capacity of 115 persons and a secure dementia care unit capacity of 35. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Report Facts
Inspection Report — Jul 31, 2018
Date: Jul 31, 2018
Visit Reason
The inspection was conducted as an interim, partial, unannounced visit by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
The inspection found a violation related to the failure to complete a written cognitive preadmission screening within 72 hours prior to admission to a secured dementia care unit. A plan of correction was submitted and partially implemented.
Citations (1)
55 Pa.Code §2600.231(c) requires a written cognitive preadmission screening completed with a physician or geriatric assessment team within 72 hours prior to admission to a secured dementia care unit. Resident 1's preadmission screening form was completed forty-three days prior to admission, which is noncompliant.
Report Facts
Number of Residents Served in Secured Dementia Care Unit: 5
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justin Lee | Executive Director | Named in the plan of correction and signature on page 4. |
| Michael Showers | Department representative on-site during inspection on 07/31/2018 as stated on page 2. |
Inspection Report — Apr 19, 2018
Original Licensing
Date: Apr 19, 2018
Visit Reason
The inspection was conducted as a licensing inspection for a new personal care home facility that was not yet serving four or more residents.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection due to the low resident census. A re-inspection will be conducted within three months to verify compliance.
Report Facts
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