Harris Health and Rehab

Inspectors wroteBased on record review, facility document review, interviews, and facility policy review, it was determined that the facility failed to ensure resident rights were maintained for one (Resident #71) of one resident reviewed.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined that the facility failed to ensure exit doors were secured and functioned properly to prevent elopement for 1 (Resident #1) of 3 residents reviewed for elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 03/23/2025 at 3:01 am, when Resident #1 was able to exit the facility without staff knowledge. The Administrator was informed of the IJ on 05/13/2025 at 3:58 pm, and notified it was considered to be Past Non-Compliance (PNC).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident ' s fingernails were kept clean for 1 (Residents #45) of 1 sample mix residents; and ensured residents were shaved to promote good personal hygiene for 1 (Resident #24) of 2 sample mix resident; ensure residents have oral care provided for 1 (Resident #45) of 2 sample mix residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the activity program was designed to meet the individual activity needs, interests and abilities for Residents who reside on the 600 Hall secure unit, and to ensure that activities were provided on the weekend for all 57 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that there was a Certified Activity Director.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hand rolls were applied to prevent further decline in range of motion (ROM) for 01 Resident #45 of 01 sample mix residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Ombudsman was notified when residents were transferred to the hospital. This had the potential to affect 57 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents individualize plan of care was revised to reflect the current needs of the resident and updated to include contractures for 01 (Resident #45) sample mix resident of 01 sample mix resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residual was checked per physicians' orders from a Gastrostomy tube prior to medication administration for 1 (Resident #32) of 1 sampled resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control measures, including handwashing, avoidance of cross contamination, and proper disposal of soiled dressings were implemented during a dressing change to prevent potential infection for 1 (Resident #1) of 1 who had orders for dressing changes.

Inspectors wroteBased on observation, interview, and record review (there is a policy) the facility failed to ensure food items stored in the refrigerator and freezer were covered, sealed, and dated, and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 60 residents who received meals from the kitchen (total census: 62), as documented on a list provided by the Dietary Supervisor on 2/22/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper Personal Protective Equipment (PPE) was readily accessible to staff for rooms with residents on Transmission-Based Precautions (TBP); failed to ensure contaminated laundry was properly contained; failed to ensure staff used appropriate donning and doffing procedures of PPE; failed to ensure PPE disposal containers were emptied when full and failed to ensure roommates of COVID-19 positive residents were tested and moved from the room without delay to prevent potential cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents may exercise their right to smoke without interference from the facility for 2 (Residents #21 and #36) of 8 (Residents #2, #10, #12, #21 #36, #37, #57 and #46) sampled residents who smoked. This failed practice had the potential to affect 15 residents who smoked as documented on a list provided by the Administrator on 02/20/23 at 1:44 PM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents living at the facility were provided a safe, clean, and comfortable homelike environment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was completed within 14 days a after a Significant Change in condition was identified to facilitate the ability to determine if any changes in care were necessary for 1 (Resident #5) of 1 sampled resident who had a decline in two or more areas of Activities of Daily Living (ADL), for 1 (Resident #44) of 1 sampled resident who had an improvement in two or more areas of ADLs, and 1 (Resident #34) of 1 sampled resident who had a new mental health diagnosis. This failed practice had the potential to affect all 62 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 02/21/23 at 10:13 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure water pitchers were accessible and provided for 3 (Residents #1, #47 and #314) of 31 (Residents #1, #2, #5, #6, #8, #10, #12, #16, #18, #19, #21, #25, #28, #29, #30, #34, #36, #37, #40, #42, #43, #45, #46, #47, #49, #50, #53, #56, #57, #60 and #314) sampled residents who required and used water pitchers and failed to ensure the interventions recommended by the Registered Dietician (RD) were implemented for 1 (Resident #50) of 8 (Residents #4, #10, #12, #18, #34, #47, #50 and #53) sampled residents who had weight loss as documented on lists provided by the Director of Nursing (DON) on 02/23/23 at 8:40 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Physicians Orders were followed for oxygen therapy and a Physicians Order was written for Bilevel Positive Airway Pressure (BiPAP)/Continuous Positive Airway Pressure (CPAP) use for 1 (Resident #29) of 2 (Residents #29 and #40) sampled residents who used a BiPAP/CPAP as documented on a list provided by the Director of Nursing (DON) on 02/23/23 at 8:40 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets as documented on a list provided by the Dietary Supervisor on 02/22/23 at 3:38 PM.

Inspectors wroteBased on observation, and interview, the facility failed to ensure the right to retain and use personal possessions including clothing for 1 (Resident #314) of 1 sampled resident who was dressed in a hospital gown. This failed practice had the potential to affect all 62 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 02/21/23 at 10:13 AM.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #53) of 1 sampled resident whose MDS was reviewed. This failed practice had the potential to affect all 62 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the MDS Coordinator on 02/21/23.

Inspectors wroteBased on record review, and interview, the facility failed to review and revise the Care Plan to meet the residents' needs for weight loss for 1 (Resident #50) of 8 (Residents #4, #10, #12, #18, #34, #47, #50 and #53) sampled residents who had weight loss with interventions as documented on a list provided by the Director of Nursing (DON) on 02/23/23 at 8:40 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident received adequate supervision and assistive devices to prevent accidents while smoking for 1 (Resident #2) of 5 (Residents #2, #12, #21, #36 and #46) sampled residents who smoked. This failed practice had the potential to affect 15 residents who smoked as documented on a list provided by the Administrator on 02/20/23 at 1:44 PM.