Harbor House Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the Resident's preference for a Geri chair for comfort to enhance their out of bed tolerance and comfort for improved quality of life for one Resident (#4), out a total sample of 24 residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure two Residents (#12 and #77), out of a total sample of 24 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed:1. For Resident #12, to ensure a physician's order for Lidocaine 4% Patch (pain relief patch) was complete and accurately reflected the location the patch was to be applied, ensure the Lidocaine Patch was applied timely per the physician's order, and to ensure the medication was administer by licensed staff; and2. For Resident #77, to ensure the correct dose of Amlodipine (blood pressure medication) was administered per physician's order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent loss of range of motion (ROM) in both knees for one Resident (#4), out of 24 residents. Specifically, Resident #4 had ROM within functional limits during last physical therapy session in April 2025 and is now presenting with severely limited right knee flexion (bending the knee) ROM to 12 degrees and left knee flexion to 7 degrees.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Residents #1), who had moderate cognitive impairment, the Facility failed to ensure they developed and implemented an Abuse Prohibition Policy that included written procedures for staff to follow related to the need to immediately report, and to whom, allegations of abuse when, on 11/08/24 at around 1:00 A.M., Resident #1 came to the nurses station with a skin tear and told Nurse #1 that someone named David stabbed him/her with a box cutter and Nurse #1 did not immediately report the allegation to the Director of Nursing or Administrator, and as a result, they were not made aware of the allegation until about 8 hours later, when the Director of Nursing reviewed Nurse #1's written Incident Report regarding Resident #1's injury.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #2), who was severely cognitively impaired and dependent upon staff for care, the Facility failed to ensure that staff implemented and followed the Facility Abuse Prohibition Policy when on 8/24/24 around 12:30 A.M., Nurse #1 was made aware of an allegation of abuse of Resident #2, that the door to his/her room was tied so that he/she could not exit if desired, and although Nurse #1 said he reported the allegation to Nurse #2, neither of them reported the allegation to facility Administration and, as a result, they were not aware of the allegation until more than 8 hours later, when Nurse #3 became aware and reported it, as required.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure facial hair was restrained during food preparation; and 2. Maintain a safe and clean microwave in one out of three kitchenettes; and 3. Maintain a safe and clean ice scoop in one out of three kitchenettes.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure for one Resident (#323), out of a total sample of 24 residents, that the Resident received care and treatment in accordance with the medical care plan. Specifically, the facility failed to perform physician-ordered treatments to the Resident's external fixator pins.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles for one Resident (#322), out of a total sample of 24 residents. Specifically, the facility failed for Resident #322, to ensure the medications were administered under direct supervision and not left at the bedside.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had experienced a fall at the Facility on 1/12/24 which resulted in him/her being diagnosed with a subdural hematoma (SDH, pool of blood between the brain and the outermost covering), the Facility failed to ensure nursing staff immediately notified his/her Physician, when on 01/31/24 at approximately 3:00 A.M., Resident #1 had a witnessed fall while being transferred by a Certified Nurse Aide (CNA), Resident #1 struck his/her head during the fall, had visible bruising and an injury to the right side of his/her face/head as a result of the fall, however the Physician was not notified until more than four hours later, at which time an order was obtained to transfer him/her to the Hospital Emergency Department (ED) for evaluation and treatment.

Inspectors wroteBased on observations, interviews, and review of the meal truck delivery schedule, the facility failed to offer a nourishing evening snack when there was a greater than 14 hours between dinner and breakfast service.

Inspectors wroteBased on record review and interview, the facility failed to hold the administration of insulin when the capillary blood glucose (CBG) was outside of the physician ordered parameters for one Resident (#86), out of a total sample of 25 residents. Specifically, the facility failed to hold the administration of insulin 26 times out of 228 administration opportunities from 2/25/23 through 5/15/23.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure 4 of 5 nourishment kitchenettes were maintained in a sanitary manner to prevent potential illness or contamination of food. Specifically, the facility failed to: 1. Ensure foods brought in from the outside were labeled, dated, and discarded timely; and 2. Maintain kitchenette refrigerators, freezers, microwaves, counters, drawers, and cabinets in a clean sanitary manner.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: 1. For Resident #66, ensure intravenous tubing connections were disinfected prior to the administration of medication, per facility policy; 2. For Resident #108, a. Ensure staff changed their personal protective equipment in between tasks for the same Resident that could result in the introductions of hazardous germs into the system, b. Ensure staff stored an enteral irrigation syringe in a manner to prevent environmental debris and germs from contaminating it in between uses, and c. Ensure enteral food was labeled and dated per facility policy; and 3. Ensure hand hygiene was performed during medication pass administration.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to implement their Antibiotic Stewardship program and ensure antimicrobial medications were used for an acceptable and prescribed indication and duration of time for two Residents (#15 and #24), in a total sample of 25 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure Advance Directives were formulated and signed by the residents, for two Residents (#339 and #8), out of a total sample of 25 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to consistently update and implement a fall care plan with interventions to prevent further falls for one Resident (#117), out of a total sample of 25 residents.

Inspectors wroteBased on observation, policy review, and interview, the facility failed for two Residents (#108 and #117) to maintain professional standards of practice, out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #108, a. Ensure medications that were administered through an enteral feeding tube met professional standards and the facility policy, and b. Provide enteral feedings as ordered by a physician; and 2. Follow the pharmacist recommendation to administer Tegretol (Carbamazepine - used to treat seizures, nerve pain, and bipolar disorder), with food for Resident #117.

Inspectors wroteBased on observation, record review, and policy review, the facility failed to ensure that a licensed nurse had completed the necessary competencies prior to administering medication and enteral feeding through a gastrointestinal tube (tube goes into the stomach) for one Resident (#108).

Inspectors wroteBased on interview and record review, the facility failed to ensure a recommendation from the consultant pharmacist was acted upon timely for one Resident #119, out of a total sample of 25 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a therapeutic diet as ordered by the physician for one Resident (#41), out of a total sample of 25 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff issued transfer notices to one Resident (#138) or their Resident Representative of three closed records and two Residents (#108 and #122) or their Resident Representatives, out of a total sample of 25 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff issued bed hold notices to one Resident (#138) or their Resident Representative of three closed records and two Residents (#108 and #122) or their Resident Representatives, out of a total sample of 25 residents.