Harbor Lakes Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to maintain pharmacy services procedures that ensure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 5 (Resident #114) residents reviewed for medication administration in that: The facility did not accurately reconcile medication orders for Resident #114. This failure could place residents at risk for improper medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure kitchen staff followed proper hand hygiene during meal preparations. This failure could place residents that eat out of the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment for 3 (Resident #9, Resident #15, and Resident #75) of 20 residents reviewed for comprehensive care plans. 1. The facility failed to ensure the interdisciplinary team reviewed and revised the plan of care quarterly for Residents #9 between 11/22/2023 & 06/19/2024. 2. The facility failed to ensure the interdisciplinary team updated the care plan after Resident #9's foley catheter was ordered on 07/16/2024. 3. The facility failed to ensure the interdisciplinary team reviewed and revised the plan of care quarterly for Resident #15 between 11/08/2023 & 07/17/2024. 4. The facility failed to ensure the interdisciplinary team updated care plan after Resident #15 hit another resident on 07/23/2024. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature as evidenced by a sample tray tested on [DATE]. This failure could affect the residents who ate food from the facility's kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for staff members (CMA H, LVN A, CNA J, & CNA K) observed for infection control. 1. The facility failed to ensure CMA H performed hand hygiene prior to putting on gloves and after taking off gloves during incontinent care. 2. The facility failed to ensure LVN A sanitized the blood pressure cuff in between using it on different residents. 3. The facility failed to ensure CNA J performed hand hygiene after taking off gloves. 4. The facility failed to ensure CNA J did not reuse disposable incontinent wipes during incontinent care. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to be free from misappropriation of resident property for 1 of 16 residents (Resident #11), reviewed for drug diversion. The facility failed to prevent the misappropriation of an unknown number of Resident #11's Oxycodone tablets (Controlled Substance requiring double lock and count every shift on 08/03/2024 from the medication cart that was never found. This failure could place residents at risk of misappropriation, and could result in increased pain, and poor quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 2 (Resident #81 and Resident #291) of 20 residents reviewed for care plan completion. 1. The facility failed to complete Resident #81's baseline care plan within the required 48-hour timeframe. 2. The facility failed to provide Resident #81 & Resident #291 a summary of their baseline care plan after completion. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 16% based on 4 errors out of 25 opportunities, which involved 1 of 5 residents (Resident #67) reviewed for medication errors. 1. The facility failed to ensure LVN A administered the correct dose of Tylenol (given for pain) to Resident #67 according to physician orders. 2. LVN A failed to administer famotidine (given for GERD), multivitamin, and magnesium oxide to Resident #67 according to physician orders. These failures could place residents at risk of inadequate therapeutic outcomes.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were properly secured for 1 of 9 (CMA Medication cart Hall 400) medication carts reviewed for proper medication storage. The facility failed to store Resident #16's Tramadol (Controlled Substance requiring double lock and count every shift) properly, when 2 pills were left in a medication cup in the top drawer of a medication cart, not labeled and not double locked on 08/13/2024. These failures could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 4 dietary staff (DA-D) reviewed for dietary support personnel. The facility failed to ensure that dietary staff (DA-D) serving in kitchen were working with a current Food Handler Certificate. This failure could place residents at risk of not having their nutritional needs met and food borne illnesses due to lack of dietary staff training.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practice, that were complete and accurate for 1 of 8(Resident #5) residents reviewed for resident records. The facility failed to ensure physician orders were followed and documented for Resident #5. This failure could place residents at risk of having errors with their care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to have an established system in place for accurate reconciliation for 4 (Hall 100, 200, 300 and 400) of 4 halls that had residents with orders for controlled substances. Licensed Staff were not signing Controlled Drugs Count Record when Controlled Drugs were reconciled at change of shift according to facility policy The facility failed to monitor expiration dates on the over-the-counter medication. These failures could affect residents by placing them at risk of drug diversion and receiving medication that will not provide the same result.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety in that: The following were observed: -1 dented 105 oz. can of peaches found in same rack as other cans. -1 unlabeled container of green beans was found in refrigerator. -1 partly covered container of tuna salad was found in the refrigerator. -1 partly covered tray of watermelon was found in the walk-in refrigerator. -Missing refrigerator temperature entry for 6/26/23. These failures could place residents at risk of food-borne illness.

Inspectors wroteBased on interview and record review the facility failed to transmit MDS data within 14 days after the facility completed a resident's MDS assessment for 1 (Resident #58) of 19 residents reviewed for timely electronic transmission of MDS data to the CMS System. The facility failed to ensure that Resident #58's completed quarterly MDS for 04/25/2023 was transmitted within the timeframe required by CMS. This failure could put residents at risk of state and federal monitors having inadequate information about the care residents require and receive.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident received an accurate assessment, that reflects the resident's status at the time of the assessment for 1 (Resident #41) out of 1 resident reviewed in accordance with professional standards. The facility failed to document MDS assessment that accurately reflected the resident's current status for Resident #41. This failure could affect the resident by placing them at risk of not receiving adequate care due to the assessment not reflecting the resident's status at the time of the assessment.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan for 2 (Resident #41 and Resident #50) of 19 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure the person-centered comprehensive care plan for Resident #41 accurately reflect the resident's current status. The facility failed to have a care plan for pain for Resident #50. These failures could place residents at risk of decreased quality of life due to pain control needs not being met and increased risk of skin-related issues due to not having their positioning needs met.