Harrison Nursing and Rehabilitation Center

Inspectors wroteBased on interview, record review, review of the facility's policy, and review of the facility's Plan of Correction (PoC) for the survey completed on 03/08/2025, with a compliance date of 03/28/2025, the facility failed to have an effective system to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. The facility failed to sustain compliance and implement effective corrective actions following a deficiency cited on the previous standard survey under 42 CFR S483.80 Infection Prevention and Control; 42 CFR S483.80 Influenza and Pneumococcal Immunizations; and 42 CFR S483.80 COVID-19 Immunization. This systemic failure placed residents at increased risk for preventable infectious diseases, including influenza, pneumococcal infections, and COVID-19. This deficient practice had the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to meet at least quarterly and have the required attendees present.

Inspectors wroteBased on observation, interview, review of a guideline from the Centers for Disease Control and Prevention (CDC), and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure that residents were informed of and able to exercise their rights regarding advance directives. Specifically, there was no documented evidence that the facility educated the residents and/or their representative on advance directives. This failure had the potential to result in residents making uninformed decisions regarding their care and treatment preferences for 7 of 41 sampled residents reviewed, Resident (R) 12, R16, R22, R33, R35, R37 and R41.

Inspectors wroteBased on observation, interview, record review, review of the controlled substance log titled Controlled Medication Shift Change Log, and review of the facility's policies, the facility failed to ensure proper documentation of the narcotic card count at each change of shift in accordance with professional standards of practice for 3 of 4 medication carts.1) Review of the 100 Hall back medication cart on 04/01/2026 at 8:30 AM, revealed the oncoming nurse failed to sign the Controlled Medication Shift Change Log on the following dates 04/01/2026, 03/24/2026, and 03/10/2026.2) Review of the 100 Hall split medication cart on 04/01/2026 at 9:45 AM, revealed the oncoming nurse failed to sign the Controlled Medication Shift Change Log on 03/24/2026 and 03/10/2026.3) Review of the 200 Hall split medication cart on 04/01/2026 at 10:00 AM, revealed on 03/16/2026, the oncoming nurse failed to sign [...]

Inspectors wroteBased on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of vaccine package inserts, and review of the facility's policy, the facility failed to ensure medications and biologicals were stored in accordance with CDC guidelines, manufacturers' recommendations, and professional standards of practice, and failed to ensure appropriate environmental controls were used to preserve their integrity. 1) Observation on [DATE] at 3:55 PM of the medication storage refrigerator revealed the temperature was at 48 F, exceeding the recommended upper limit. Review of the medication refrigerator temperature logs revealed multiple instances of temperatures falling below the minimum required range for proper medication storage (36 F to 46 F). During the month of [DATE], temperatures were documented below 36 on 13 out of 31 days. [...]

Inspectors wroteBased on interview, facility policy review, and review of the Facility Assessment, the facility failed to provide staffing numbers in the facility assessment based on the resident population and their needs for care and support to ensure there was sufficient staff to meet the needs of the residents at any time. There was also no plan in the facility assessment for recruitment and retention. Additionally, the lack of staffing minimums in the facility assessment contributed to complaints of slow call light response time for 7 of 41 sampled residents, Resident (R) 2, R16, R19, R30, R34, R45, and R52.

Inspectors wroteBased on interview, record review, the Centers for Disease Control and Prevention (CDC) guidance, and review of the facility's policy, the facility failed to ensure each resident was offered influenza and pneumococcal immunizations, and each resident or resident representative received education on the benefits, potential risks, and side effects associated with influenza and pneumococcal immunizations. [...]

Inspectors wroteBased on interview, record review, and review of the Centers for Medicaid and Medicare Services (CMS) recommendations, the facility failed to ensure each resident was offered the COVID-19 vaccine and that each resident or resident's representative received education regarding the benefits, potential risks, and side effects associated with the COVID-19 vaccine. Additionally, the facility failed to ensure the resident's medical record included documentation that, at a minimum, the resident or resident's representative was provided education regarding the benefits and potential risks of the COVID-19 vaccine, each dose of the COVID-19 vaccine administered to the resident, or that the resident did not receive the vaccine due to medical contradictions or refusals for 5 of 5 sampled residents, Residents (R) 16, R22, R35, R37, and R41.

Inspectors wroteBased on observation, interview, record review, and review of facility's policies, the facility failed to ensure accommodation of needs and preferences for 2 of 3 sampled residents related to room accommodation and activity preferences, Resident (R) 7 and R8.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to notify the resident of the transfer in writing and maintain a copy of the notice in the resident's medical record. The facility failed to ensure the transfer or discharge was documented in the resident's medical record. The facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 1 sampled residents, Resident (R) 16. Record review and interviews revealed R16 was not notified in writing of her 07/19/2025 transfer to the hospital, to include the reason for the transfer, the duration of the bed hold, and the facility's policies regarding bed holds. There was no written transfer or bed hold documented in the resident's medical record. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 13 sampled residents, Residents (R) 16 and R35.1. During an interview with R16 on 03/31/2026 at 9:45 AM, she stated she had chronic back pain. However, review of R16's care plan revealed no non-pharmacological interventions were developed or implemented to address the resident's chronic pain.2. During an interview with R35 on 03/31/2026 at 10:15 AM, she stated she had chronic bilateral lower extremity and left knee pain. However, review of R35's care plan revealed no non-pharmacological intervention was developed or implemented to address the resident's chronic pain.

Inspectors wroteBased on observation, interview, record review, review of the facility's procedure manual, Lippincott Nursing Procedures, and the staff's Skill Competency sheets, the facility failed to ensure residents had their urinary collection bags secured properly below the bladder for 1 of 2 residents assessed for urinary catheters, Resident (R) 33.

Inspectors wroteBased on observation, interview, record review, and review of the facility's procedure resource, Lippincott Nursing Procedures, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with physician orders and professional standards of practice for 3 out of 3 sampled residents, Resident (R) 16, R22, and R38.

Inspectors wroteBased on observation, interviews, and review of the facility's policies, the facility failed to ensure the area around the two outside dumpsters was free of trash, and the elimination of debris prevented the potential for vermin and pest attraction. This had the potential to affect all 50 residents who resided in the facility.

Inspectors wroteBased on interview and review of the facility's policy, the facility failed to ensure all residents had the right to send and receive mail on Saturdays. This affected all 49 current residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards. Observation revealed undated, opened, and expired medications in 3 of 4 medication carts and 1 of 1 treatment carts. Those medications included inhalers, an insulin vial, insulin pens, laxatives, antifungal powder, and topical creams.

Inspectors wroteBased on observation, interview, record review, review of the facility's job descriptions, and review of the facility's plan of correction (PoC), dated 03/12/2024, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) process. The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life that were achieved and sustained. Observation on 01/22/2025 at 10:00 AM revealed insulin lispro was opened, in use, and dated with an expiration date of 01/16/2025. Review of the previous survey, dated 01/07/2024 to 01/11/2024, revealed a repeat issue was found with the expired insulin being used. This affected all 49 current residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the manufacturer's instructions for use, and review of the facility's policies, the facility failed to establish and 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 2 of 26 sampled and supplemental residents, Residents (R) 44 and R21. Additionally, the failed to assess and monitor the building's water system for Legionella and other opportunistic waterborne pathogens affecting the total census of 49. 1. [...]

Inspectors wroteBased on interview, record review, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's policy, the facility failed to ensure the medical record included documentation of the resident's or resident representative's (RR) education regarding the benefits and potential side effects of immunizations for 5 of 5 residents sampled for immunizations (Resident (R) 6, R9, R16, R21, and R44).

Inspectors wroteBased on interview, record review, review of the Centers for Medicaid and Medicare Services (CMS) document, and review of the facility's policy, the facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for 4 of 4 sampled staff, Licensed Practical Nurse (LPN) 2, LPN7, Certified Nurse Aide (CNA) 2, and the Business Office Manager (BOM).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were treated with dignity and respect related to privacy and providing a privacy/dignity bag to cover an indwelling urinary catheter bag for 1 of 13 sampled residents (Resident (R) 9). Observations on 01/21/2025, 01/22/2025, 01/23/2025, and 01/24/2025 revealed R9 was not provided a dignity cover for her catheter bag. R9's Foley catheter bag was visible from the hallway with all observations.

Inspectors wroteBased on interview, record review, review of the Hospice agreement, and review of the facility's policies, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide an effective and person-centered care plan for the resident that met professional standards of quality care for 1 of 13 sampled residents, Resident (R) 102. Resident 102 was admitted to the facility on [DATE] with the physician's order, dated 01/14/2025, to admit with Hospice services. However, review of R102's Baseline Care Plan, not dated, revealed no focus area for Hospice care until 01/19/2025.

Inspectors wroteBased on observation, interview, record review, and review of the facility's documents and policies, the facility failed to develop and implement a comprehensive, person-centered care plan to meet a resident's medical, nursing, and psychosocial needs for 2 of 13 sampled residents (Residents (R) 9, and R16). 1. R9 was admitted to Hospice on 01/17/2025. However, review of the person-centered care plan revealed the Hospice care area was not developed until 01/21/2025, four days after admission to Hospice care. 2. R16 did not have a person-centered care plan developed to address the resident's non-compliance with medical treatments and regimens or interventions to address the resident's respiratory care and ordered oxygen therapy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide oxygen therapy according to the Physician's Order for 1 of 13 sampled Residents (Resident (R) 16). Observations on 01/21/2025, 01/22/2025, 01/23/2025, and 01/24/2025 revealed staff failed to ensure R16's oxygen flow was set at three liters per minute (LPM) per the Physician's Orders.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to implement the intervention of the use of a mechanical lift for one (1) of three (3) sampled residents, Resident #39. The facility assessed Resident #39 and care planned the resident to require the use of a mechanical lift (an assistance device used to transfer residents from one (1) surface to another who required support more than the manual support provided by caregivers alone) with two (2) staff assisting. However, on 02/06/2024, State Registered Nurse Aide (SRNA) #8 and Licensed Practical Nurse (LPN) #1 transferred Resident #39 from the bed to the Geri chair (geriatric, a large padded chair with a wheeled base designed to assist patients with limited mobility) then later from the Geri chair to the bed without the use of the mechanical lift. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the use of assistance devices to prevent injury for one (1) of three (3) sampled residents (Residents #39). On 02/06/2024 staff transferred Resident #39 from the bed to chair then back to bed without using a mechanical lift (an assistance device used to transfer residents from one (1) surface to another who required support more than the manual support provided by caregivers alone). Resident #39 sustained an intertrochanteric comminuted fracture (the bone was broken in at least two (2) places) to the right proximal femur and a fracture to the thoracic (T)11 vertebrae.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for three (3) of thirty-seven (37) sampled residents (Residents #29, #12, and #26). Resident #29 sustained a laceration to the chin requiring six (6) sutures on 02/21/2023 when the bed the resident was in was not locked and rolled causing the resident to fall while receiving care per one (1) persons assistance when the resident was assessed and care planned for two (2) person assist. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to revise the Care Plan for two (2) of thirty-seven (37) residents (Residents #5 and #39). Resident #39 was care planned to be nutritionally at risk. However, care plan interventions were not updated following a significant weight loss. Resident #5 experienced nine (9) falls from 01/12/2023 through 11/02/2023. One fall resulted in a fractured wrist. There was no evidence that interventions following the falls were placed on the care plan or dated. (See F689 and F692)

Inspectors wrote1. Review of Resident #29's Electronic Health Record (EHR) revealed the facility admitted the resident on 03/04/2022 with diagnoses to include unspecified dementia without behavioral disturbance, need for assistance with personal care, and other reduced mobility. The facility assessed Resident #29, in a Quarterly Minimum Data Set (MDS) Assessment, dated 07/20/2023, as severely cognitively impaired and requiring extensive assist of two (2) with bed mobility and with incontinence care. Review of Resident #29's Comprehensive Care Plan, last reviewed 10/17/2023, revealed the resident was care planned for two (2) person assist with toileting and bed mobility, but these interventions were undated. Resident #29 was also care planned for transfers with a mechanical lift, which was also undated. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain acceptable parameters of nutritional status for one (1) of thirty-seven (37) sampled residents (Resident #39). Resident #39 lost greater than ten percent (10%) of his/her body weight in the past six (6) months and over twenty percent (20%) in a year. The facility failed to ensure that interventions were implemented timely to prevent the weight loss.

Inspectors wroteBased on observation, interview, review of the facility's job descriptions, and review of the facility's policy, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. A broken tile was observed in the middle of the hallway in front of room [ROOM NUMBER] and was not identified by facility staff. This provided a potential fall hazard to visitors as well as ambulatory residents and residents that utilized walkers and wheelchairs for mobility.

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure food was distributed in accordance with professional standards. Serving ware, specifically food scoops, were observed during the initial tour with food waste/debris dried on them. Although this was identified to staff, observation of the tray line revealed scoops set out for food service had dried food on them. Several coffee cups ready for service did not appear clean.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to treat each resident with dignity in an environment that promoted his/her quality of life for two (2) of thirty-seven (37) sampled residents (Residents #26 and #39). Resident #26 stated staff took him/her to the shower dressed only in his/her brief and a sheet, which made him/her feel exposed and embarrassed. Resident #26 further stated his/her mentally ill roommate put feces on Resident #26's bedside table, which made him/her feel disgusted and frustrated. Resident #39 was observed wearing the same clothes for consecutive days, smelling of urine, with dirty, uncombed hair.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to turn and reposition according to professional standards of care for two (2) out of thirty-seven (37) sampled residents (Residents #26 and #39). The facility further failed to apply Resident #26's brace to his/her left hand contracture according to the care plan.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide incontinence care for Resident #26, which resulted in skin breakdown.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide respiratory care consistent with professional standards and physician's orders for one (1) out of thirty-seven (37) sampled residents (Resident #35). Per physician's order, Resident #35's oxygen tubing was due to be changed on [DATE] but was observed to be out of date on [DATE].

Inspectors wroteBased on interview, record review, review of a document on the website www.drugs.com, and review of the facility's policy, it was determined the facility failed to ensure residents were prescribed psychotropic drugs when the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. In addition, the facility failed to ensure residents received gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (1) of thirty-seven (37) sampled residents (Resident #12). Resident #12 was prescribed Seroquel (an antipsychotic medication), without an approved diagnosis, from 08/08/2023 to 01/11/2024. As a possible result related to the side effects of the medication, Resident #12 sustained nine (9) documented falls from 09/24/2023 to 01/05/2024. (See F656 and F689)

Inspectors wroteBased on observation, interview, and review of data from https://www.accessdata.fda.gov, it was determined the facility failed to store drugs according to professional standards for one (1) of thirty-seven (37) sampled residents (Resident #30). Resident #30's insulin was labeled as opened on [DATE] and expired on [DATE] according to manufacturer's recommendations, but was still being used for the resident.