Harbourwood Post-Acute and Rehabilitation Center

Inspectors wroteBased on interview, record review and clinical professional standards, the facility failed to ensure medications were administered as prescribed, with physician orders for four residents (#1, #2, #3, and #10) out of six sampled. Findings Included: A review of Resident #1's admission record showed an admission date of 4/22/2026, with diagnoses including type 2 Diabetes Mellitus, protein calorie malnutrition, and high blood pressure. A review of Resident #1's physician order summary report showed orders dated 4/22/26 for the following: oxycodone 5 mg (milligram) by mouth every 6 hours as needed for pain, pain evaluation every shift to monitor the resident's pain level, and pain management consult with treatment as needed. A review of Resident #1's nurse's note dated 4/23/26 at 3:57 p.m. showed: Resident ambulating around unit. Complains of pain (9/10). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the residents' right to be free from abuse for one resident (#3) out of 3 sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to follow professional standards of care and protect the residents' right to be free from neglect for two residents (#3, and #4) out of four residents sampled related to 1) failure to follow up physician orders for laboratory and radiology testing, and failure to report abnormal laboratory test results.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for three residents (#1, #3, and #4) out of four residents sampled related to: 1) failure to recognize a change in condition and provide care resulting in a hospitalization 2) failure to follow physician orders for laboratory testing; 3) failure to report abnormal laboratory results. Findings Included: A review of Resident #3’s admission record revealed an initial admission date of 8/20/24 and a readmission date of 7/20/25 from a hospital stay, and a discharge date of 3/30/25, with diagnoses to include metabolic encephalopathy-7/20/25, acute renal failure with hypoxa-7/20/25, atrial fibrillation,- 7/20/25 and chronic kidney disease (stage 2)-8/20/24. [...]

Inspectors wroteBased on interviews and record review the facility failed to review and revise the comprehensive care plan for one resident (#1) out of 3 residents reviewed. Based on interviews and record review the facility failed to review and revise the comprehensive care plan for one resident (#1) out of 3 residents reviewed.

Inspectors wroteBased on observations, review of medical records and facility policies, and interviews with residents and physicians, the facility failed to protect the resident's right to be free from physical, verbal and psychological abuse and failed to identify, correct and intervene in situations in which abuse and neglect was more likely to occur for one resident (#1) of two residents sampled.

Inspectors wroteBased on observations, interviews and record review, the facility failed to assess, develop and implement a care plan related to a documented PTSD (Post Traumatic Stress Disorder) diagnosis and failed to care plan potential trauma triggers for one resident (#1) of two residents sampled.

Inspectors wroteBased on interviews and record review, the facility failed to report and thoroughly investigate an allegation of abuse in a timely manner for one resident (#31) out of three residents sampled.

Inspectors wroteBased on interview and record review the facility failed to notify the attending physician, resident, and /or resident representative about a change in condition related to radiology results for two residents (#37 and #38) out of three residents sampled.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents and/or resident representatives, were informed and provided written notice of the right to accept or decline medical and surgical treatments to formulate an Advance Directive for ten residents (#68, #167, #1, #93, #15, #48, #76, #43, #168, and #57) out of forty-eight residents sampled.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a safe, clean, home like environment on one (2nd floor) out of 2 floors observed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) were completed accurately and updated to reflect new Mental Illness (MI), or Suspected Mental Illness (SMI) diagnoses for five residents (#51, #66, #75, #57, and #69) of forty-nine sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) care related to 1. removal of facial hair for one (#18) of 31 sampled residents and 2. did not ensure the cleaning and trimming of fingernails for two (#68 and #48) out of 31 residents sampled. Findings Included: 1. During an interview on 12/02/2024 at 10:26 a.m., resident was observed sitting in a wheel chair in the hallway. She stated she was leaving her room for a little while. She was observed to have strands of white facial hair on her chin. She stated if she could just get a razor, she could take care of them herself. She stated no one had offered to help her. During an interview on 12/04/2024 at 5:30 p.m., resident #18 was observed lying in bed dressed in a red sweater. She was observed to have strands of white facial hair on her chin. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure wound care was provided for one resident (#93) of two sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. Twenty-eight medication administration opportunities were observed, and seven errors were identified for four residents (#4, #15, #68 and #93) of eight residents observed. These errors constituted a medication error rate of 25%. Findings Included: 1. On 12/04/24 at 7:28 a.m., during medications administration observation with Staff P, Registered Nurse (RN), Staff P administered Fiasp FlexTouch (insulin aspart) 30 units subcutaneously (SQ) to Resident #15. Review of Resident's #15's order summary report, active orders as of 12/4/24 revealed orders to include Fiasp FlexTouch 15 unit subcutaneously in the morning for (Diabetes Mellitus (DM) and Fiasp FlexTouch 15 unit subcutaneously with meals for DM. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to notify the ordering practitioner of Radiology results for one resident out of eight residents sampled (#67). Findings Include: On 12/2/2024 at 10:00 am., Resident #67 was sitting up in her wheelchair, dressed well-groomed with her call light within reach. She was presented with no signs of distress. She stated she had an incident two weeks ago when two nursing aides pulled her up in bed. She stated she felt a sharp pain in her back and legs after they repositioned her. She stated one of the aides told the nurse about the resident complaint and was provided with an x-ray. She stated she was never told the results of the x-ray findings. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee developed and implemented an effective Quality Improvement and Performance action plan, to correct deficient practice identified during a recertification survey conducted on 12/2/24 to 12/5/25, related to citations at F 552, F 677, F 686, F 777, and F 880.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow professional standards to help prevent the development and transmission of communicable diseases and infections related to 1. hand hygiene for three (#85, #93, and #104) of eight sample residents, 2. Personal Protective Equipment (PPE) use for one (#27) of one sampled resident, and 3. cleaning of equipment for two (#4 and #27) of eight sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure dignity was providing by protecting and valuing residents' private space by knocking before entering one (#29) resident's room out of 31 residents sampled. Findings Included: During an observation on 12/02/2024 at 10:33 a.m., a staff member, in black scrubs was observed entering Resident #29's room without knocking or being invited in by Resident #29. During an observation on 12/03/2024 at 9:00 a.m., a staff member, in black scrubs was observed entering Resident #29's room without knocking or being invited in by Resident #29. During an observation on 12/04/2024 at 3:12 p.m., a staff member, in black scrubs was observed entering Resident #29's room without knocking or being invited in by Resident #29. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the opportunity to participate in care planning for one resident (#44) out of 8 residents sampled.

Inspectors wroteBased on observation and interview, the facility failed to ensure personal privacy was honored by providing a private space for one resident (R #16) out of 31 residents sampled to use the phone. Findings Included: During an observation on 12/03/2024 at 10:30 a.m., Resident #16 was observed sitting in a wheelchair in front of the nurse's station on the phone. During an interview on 12/03/2024 at 4:30 p.m., Resident #16 stated she did not want a phone in her room because there were plenty of other phones around the house she could use. An observation of Resident #16's room revealed Resident #16 did not have a phone in her room. Review of Resident #16's admission record revealed an admission date of 10/21/2024. Review of the Resident #16's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 revealing severe cognitive impairment. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to accurately complete resident assessments, reflective of the resident's status at the time of the assessment, for two Residents (#77 and #113) of eight residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident centered care plan was developed for one resident (#57) out of 31 residents sampled, related to Post-Traumatic Stress Disorder. Findings Included: During an interview on 12/2/2024 at 2:48 p.m. with Resident #57's family member (FM), he stated he is happy with the care his father is receiving and had no concerns. He stated he was unsure of any triggers regarding resident #57's Post Traumatic Stress Disorder (PTSD) and the facility, and staff are good at handling his care. Review of Resident #57's admission Record revealed an initial admission date of 3/15/2022 and a readmission date of 4/30/2024. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to coordinate audiology services for one resident out of eight residents sampled (#77).

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide one (#92) of eight sampled residents with therapeutic food to meet the resident's nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor food choices for three (#1, #167, and #19) of forty-forty sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to honor the right of a resident to share a room for two (Resident #1 and #2) of five sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a prompt effort to resolve a grievance regarding a roommate for one (Resident #1) of five sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement an effective infection control and prevention program to prevent the spread of infection by 1.) failing to ensure a sufficient supply of Personal Protective Equipment (PPE) was made available outside of resident rooms under transmission based precaution for two (#8 and #9) of six residents in the facility under transmission based precautions; 2.) failing to ensure staff donned appropriate PPE before entering the rooms of residents on transmission based precautions for two (#8 and #9) of six residents in the facility under transmission based precautions; 3.) failing to ensure residents under transmission based precautions had physician's orders in place for two (#8 and #9) of six residents in the facility under transmission based precautions; [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure care and services for intravenous (IV) sites was provided in accordance with professional standards of practice for two (#6 and #7) of three residents sampled for intravenous therapy.

Inspectors wroteBased on interview and record review, the facility failed to provide care consistent with professional standards of practice related to assessments and promoting the healing of pressure ulcers for two (#1, #2) of three sampled residents.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure meals were served in a dignified manner related to staff standing when assisting residents with meals, during 2 of 2 observations for Residents #14 and #102, and failed to ensure assistance out of bed was provided per resident's choice for Resident # 42.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their policy to store medications appropriately in four of six medication carts (First and Second Floor Halls), failed to appropriately secure medications for two (Residents #49, and# 67) of two residents; and did not ensure removal of one expired medication from one (Memphis Hall Cart) of six medication carts and one medication from one (First Floor Medication Room) of two medications rooms.

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by 1. failed to ensure one of one low temperature dish machine was operating effectively and per the machine specifications during one of four days observed. 2. failed to ensure one of three facility refrigerators, used by staff and residents, were clean and maintained with packaged outside source food items properly labeled and dated.

Inspectors wroteBased on observations, staff interviews, and facility file review, the facility failed to ensure a safe, clean, comfortable, and homelike environment in one of two main dining rooms and two of two community showers/shower chairs as evidenced by 1. The tables where residents eat were not cleaned and wiped down between and after each meal service during two of four days observed, 4/12/2021 and 4/13/2021. 2. The facility also failed to ensure that shower chairs were cleaned between and after resident use, during four of four days observed, 4/12/2021, 4/13/2021, 4/14/2021 and 4/15/2021.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (Resident #84) of three sampled residents received wound care consistent with professional standards for two in house acquired wounds. Findings Included: Wound care for Resident #84 was observed on 4/15/21 at 10:34 a.m. with Staff E, Registered Nurse (RN) and Staff F, Licensed Practical Nurse (LPN) assisting. Staff E, RN donned gloves without hand hygiene and used bleach wipes to clean the resident's bedside table then doffed gloves. He washed his hands and donned a gown before he began to gather supplies of sterile water, [antimicrobial wound cleanser] solution with 4 x 4' s' for soaking, wound cleanser, cotton tipped applicator, and xeroform with two large foam dressings. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure that respiratory care was provided consistent with professional standards of practice for one (Resident # 37) of two residents reviewed for oxygen use. During a facility tour on 04/12/21 at 9:35 a.m., Resident #37 was observed in her room, oxygen noted in use. Resident #37 stated that she used oxygen as needed, probably about three times a day. Resident #37 was noted to have an oxygen concentrator in her room with cannula and tubing in place. Resident #37 was also observed with a portable oxygen unit behind her wheelchair bag. A review of Resident #37's EMR (Electronic Medical Record) on 04/13/21 revealed no physician's order for oxygen. The EMR revealed only an order to replace oxygen tubing on Tuesday night as needed, initiated on 01/05/21. [...]