Harbor Health & Rehab

Inspectors wroteBased on record review and interview, the facility failed to ensure Care Plans were updated with interventions for residents who had behaviors, falls, schizophrenia, and abuse care plans for 4 of 4 residents reviewed for care plans (Resident B, C, D, and E)

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Responsible Party was notified of a roommate change for 1 of 3 residents reviewed for notification of change. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure care plan meetings occurred for 1 of 3 residents reviewed for care planning. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with behaviors received appropriate treatment and services to meet his needs, related to ongoing consistent behaviors without updated behavior interventions following an incident on 12/24/26 that resulted in 2 hospitalizations within 48 hours, and lacked 15-minute safety checks upon the resident's return for 1 of 4 residents reviewed for behaviors. (Resident C)

Inspectors wroteBased on record review and interview, the facility failed to ensure clinical records were accurate and complete related to 15 minute safety checks for residents who had behaviors for 1 of 4 residents reviewed for abuse. (Resident C)

Inspectors wroteBased on record review and interview, the facility failed to ensure the mandatory submission of staffing information, based on payroll data, was electronically submitted to iQIES. This had the potential to affect the 70 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to not offering beverages to residents while participating in activities. The facility also failed to ensure personal care signs were not posted in resident rooms for 4 of 4 residents reviewed for dignity. (Residents 2, 20, 1, and 43)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's privacy was respected related to completing a room search of their personal belongings without permission for 1 of 1 resident reviewed for privacy. (Resident 4)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADLs) related to having their hair washed for 1 of 3 residents reviewed for ADLs. (Resident 24)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure follow up documentation after a fall was completed for 1 of 1 resident reviewed for change in condition. The facility also failed to apply compression wraps as ordered for edema for 1 of 1 resident reviewed for edema. (Residents 19 and 1)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate supervision was provided related to the serving of hot beverages and thickened liquids as well as a resident using a vape pen in their room for 2 of 3 residents reviewed for accidents. (Residents 2 and 63)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure indwelling Foley (urinary) catheter bags and tubing were kept off of the floor, nephrostomy tube equipment was changed and the site was monitored for 1 of 2 residents reviewed for Foley catheters and 1 of 1 resident reviewed for nephrostomy tubes. (Residents 1 and 6)

Inspectors wroteBased on observation, record review, and interview, the facility failed to check for peg tube (a tube inserted directly into the stomach for nutrition) placement properly prior to medication administration for 1 of 1 resident observed for peg tube medication administration. (Resident 11)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an implanted port device was assessed and monitored for 1 of 1 resident reviewed for parental/IV fluids. (Resident 63)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure proper medication storage related to pre-filled saline syringes used to flush implanted port devices stored in the resident's room for 1 of 6 residents observed during medication pass. (Resident 74)

Inspectors wroteBased on observation and interview, the facility failed to ensure food was served at a palatable temperature for one of one meal observation. (Residents 4, 24, and 42)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received physical therapy as ordered by the physician for 1 of 1 resident reviewed for rehabilitation services. (Resident 10)

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical record was complete and accurate related to inaccurate tube feeding residual amounts and incorrect resident information in a record for 1 of 21 records reviewed. (Resident 11)

Inspectors wroteBased on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a resident remaining on an antibiotic after the organism was determined to be resistant to the medication and prescribing antibiotics for not true infections based on the McGeer Criteria for 1 of 1 resident reviewed for urinary catheters. (Resident 8)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and signed out on the Medication Administration Record (MAR) for 1 of 3 residents reviewed for respiratory care. (Resident E)

Inspectors wroteBased on record review and interview, the facility failed to ensure a dependent resident received adequate assistance and supervision to prevent accidents related to only one staff person assisting during a mechanical lift transfer for 1 of 2 residents reviewed for falls. (Resident 3) This deficient practice resulted in the resident falling and receiving a fracture to her leg. The deficient practice was corrected on 7/22/24, prior to the start of the survey, and was therefore past noncompliance. The facility identified the concern, completed a house wide sweep of the Hoyer lifts (a mechanical lift) and Hoyer slings, an inservice was held related to transfer techniques and two person staff assist while using the Hoyer lift, return demonstration by staff was observed, and audits related to the use of the Hoyer lift were being completed weekly.

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was in good repair related to marred walls, loose baseboards and missing bolts around the toilet for 1 of 2 floors observed. (First Floor)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to a cognitively impaired dependent resident being dressed in a hospital gown during the day for 1 of 1 resident reviewed for dignity. (Resident 58)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL's) related to the cleaning and cutting of fingernails, oral care, and getting out of bed for 2 of 10 residents reviewed for ADL's. (Residents 45 and 58)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a personalized activity program for cognitively impaired and dependent residents related to ongoing stimulation and being invited to activities for 2 of 2 residents reviewed for activities. (Residents 24 and 58)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure areas of discoloration and treatments for non-pressure areas were completed and/or ordered for 2 of 2 residents reviewed for non-pressure related skin conditions (Residents 13 and 57)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure glasses were received as ordered and a follow up audiology (a physician who treats hearing issues) appointment was completed for 3 of 4 residents reviewed for vision and hearing. (Residents 2, 45, and 34)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a pressure sore received the necessary treatment and services to promote healing related to providing a treatment as ordered by the physician for 1 of 2 residents reviewed for pressure ulcers. (Resident 58)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a suprapubic foley (urinary) catheter received foley catheter care for 1 of 1 resident reviewed for catheters. (Resident 45)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was positioned upright at least 45 degrees while an enteral feeding was infusing into a peg tube (a tube inserted directly into the stomach to provide nutrition) for 1 of 1 resident reviewed for tube feeding. (Resident 58)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate for 1 of 3 residents reviewed for respiratory care. (Resident 13)

Inspectors wroteBased on record review and interview, the facility failed to establish and/or maintain a system that accounted for, periodically reconciled, and ensured the disposition of all controlled drugs, related to inaccurate documentation of narcotic medications for 1 of 1 resident reviewed for narcotics. (Resident 33)

Inspectors wroteBased on record review and interview, the facility failed to appropriately monitor blood pressures (BP) related to medications with BP parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 58)

Inspectors wroteBased on record review and interview, the facility failed to ensure an adequate indication for the use of an antipsychotic medication was documented in the clinical record for 1 of 5 residents reviewed for unnecessary medication. (Resident 5)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received routine dental services related to decayed and broken teeth for 1 of 2 residents reviewed for dental services. (Resident 45)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was prepared in a form to meet individual needs related to not following the pureed recipe. This had the potential to affect 2 residents who received a pureed diet. (Cook 1) On 8/7/24 at 11:37 a.m., a pureed demonstration of barbeque chicken was observed with [NAME] 1. The pureed barbeque chicken was precooked and 2 servings were measured out from the mechanical barbeque chicken mixture and added to the blender. There were no additional ingredients that were added to the mixture. The barbeque chicken puree was pudding thick, and the mixture was even with no clumps. [NAME] 1 measured out 2 servings and placed them in 2 serving bowls. On 8/7/24 at 11:45 a.m., [NAME] 1 measured out 2 servings of precooked broccoli and added to the blender. There were no additional ingredients added to the mixture. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to documentation of a dialysis access site for 1 of 1 resident reviewed for dialysis (Resident 2) and the correct medication administration route for 1 of 1 resident reviewed for unnecessary medications (Resident 58).

Inspectors wroteBased on record review and interview, the facility failed to identify unresolved quality deficiencies, which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process, as evidenced by the number of repeated deficiencies cited for pest control related to gnats in resident rooms. This deficient practice had the potential to affect 60 of 60 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the residents' environment was free of pests related to gnats for 1 of 1 residents observed with gnats in their room. (Resident 33)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure fall interventions were care planned for a resident with a history of falls for 1 of 5 care plans reviewed. (Resident E)

Inspectors wroteBased on record review and interview, the facility failed to ensure resident received the necessary care and services related to lack of blood glucose parameters in place and Physician notification of elevated blood glucose levels for 1 of 3 residents reviewed for diabetic care. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure treatment orders were obtained timely for a newly developed pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident B)

Inspectors wroteBased on record review, and interview, the facility failed to ensure residents with pressure ulcers received the necessary care and services to treat and improve the wounds related to the lack of documentation and obtaining orders for the treatment of pressure ulcers and following the dietician's recommendations for healing for 2 of 3 residents reviewed for pressure ulcers. (Residents E and B)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident only received food in the form ordered by the physician related to the consumption of a regular donut during a transport which led to a choking incident and resulted in respiratory failure, cardiac arrest and ultimately his demise for 1 of 3 resident reviewed for mechanically altered diets. (Resident B) The immediate jeopardy began on 7/18/23 when the Administrator fed Resident B a regular donut, not in pureed form, which he consumed during a facility transport. Soon after, he turned blue, started choking and the Heimlich maneuver was performed. He then stopped breathing, CPR was initiated, and he was transferred to the hospital. The Regional [NAME] President Operations was notified of the immediate jeopardy on 7/25/23 at 10:51 a.m. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was monitored for signs and symptoms of constipation. The lack of assessment and monitoring resulted in the resident being hospitalized with a severe fecal impaction for 1 of 1 residents reviewed for constipation. (Resident 60) The facility also failed to ensure a fall follow up assessment was completed and an assessment including vital signs was documented prior to hospitalization for 1 of 2 residents reviewed for falls and 2 of 3 residents reviewed for hospitalization. (Residents E and 12)

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food under sanitary conditions related to built up grease on the stove top, open food containers, and uncovered food in the freezer for 1 of 1 kitchens observed. This had the potential to affect the 64 residents who received food from the kitchen. (The Main Kitchen)

Inspectors wroteBased on record review and interview, the facility failed to identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process, as evidenced by the number of repeated deficiencies cited for quality of care related to follow up documentation and assessment after a fall. This deficient practice had the potential to affect 64 of 64 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide documentation of care conferences held with the resident or resident's family and facility staff for 7 of 7 residents reviewed for care planning decisions. (Residents 60, 12, 46, 52, 18, 16, and 10)

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment, as well as the kitchen area, was clean and in good repair related to dirty floors, marred walls, loose baseboards and lime build up in for 1 of 2 floors and the Main Kitchen. (Second Floor and the Main Kitchen)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the resident's preference was honored for the number of medications received for 1 of 1 residents reviewed for choices. (Resident C)

Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate documentation, such as a discharge summary, was completed prior to transferring a resident to the hospital for 1 of 3 residents reviewed for hospitalization (Resident D).

Inspectors wroteBased on record review and interview, the facility failed to ensure a Care Plan was developed for a resident who had a new Schizophrenia diagnosis for 1 of 19 residents reviewed for Care Plan development. (Resident 10)

Inspectors wroteBased on record review and interview, the facility failed to ensure documentation of discharge planning was completed for 1 of 1 closed records reviewed for discharge. (Resident 70)

Inspectors wroteBased on record review and interview, the facility failed to complete the recapitulation of the resident's stay prior to discharge for 1 of 1 closed records reviewed for discharge. (Resident 70)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had access to receive services for impaired vision for 1 of 1 residents reviewed for vision and hearing. (Resident 60)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a Stage 4 pressure ulcer received the necessary care and services to treat and improve the wound related to not providing a wound vac in a timely manner for 1 of 3 residents reviewed for pressure ulcers. (Resident 60)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure splints were applied as ordered for 1 of 1 residents reviewed for limited range of motion (ROM). (Resident 46)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a history of falls had fall interventions in place to prevent further injury related to not wearing non-skid socks for 1 of 2 residents reviewed for falls. (Resident E)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents with complex urinary tract infections were seen by the urologist and residents with suprapubic (inserted through the abdomen) foley (urinary) catheters had them changed on a monthly basis for 2 of 3 residents reviewed for catheters. (Residents 60 and 2)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status related to meal consumption records not completed and dietary supplements not given to the resident for 1 of 4 residents reviewed for nutrition. (Resident 60)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure lung sounds were assessed prior to administering nebulizer treatments and staff remained with the resident during the treatment for 1 of 1 nebulizer treatments observed. (Resident 271)

Inspectors wroteBased on record review and interview, the facility failed to ensure ongoing communication with the dialysis center was completed with each dialysis session for 1 of 1 residents reviewed for dialysis. (Resident 12)

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were managed appropriately related to missed insulin doses and medication not held as ordered for 1 of 6 residents reviewed for unnecessary medications (Resident 12).

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive unnecessary medications related to PRN (as needed) anti-anxiety medication only administered after non-pharmaceutical interventions were attempted for 1 of 6 residents reviewed for unnecessary medications. (Resident E)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents observed during medication pass. Three errors were observed during 30 opportunities for errors during medication administration. This resulted in a medication error rate of 10%. (Residents 34 and 5)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were labeled and stored correctly for 1 of 5 residents observed during medication administration. (Resident 5)

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medical record was complete and accurate related to dialysis fistula monitoring for 1 of 1 residents reviewed for dialysis. (Resident 12)

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program to ensure the facility was free from pests related to live gnats and flies for 2 of 2 residents observed with gnats in their rooms. (Residents G and F)

Inspectors wroteBased on observation and interview, the facility failed to ensure residents and/or visitors could access the survey inspection results without having to ask. This had the potential to affect 64 of the 64 residents who resided in the facility.