Harrogate Village

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following:On 02/05/2026 at 9:47 AM, the surveyor accompanied by the Director of Culinary Services (DOCS), observed the following in the kitchen: Upon entry to the kitchen the surveyor confirmed with the DOCS that the facility utilized a high temperature dish machine that was in operation for the post-breakfast meal service. The surveyor requested to see the dish machine temperature log prior to inspection of the dish machine. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the required members were present during the quarterly Quality Assurance and Performance Improvement (QAPI) Committee Meetings. This deficient practice occurred during 1 of 4 meetings reviewed and was evidenced by the following:On 2/9/26 at 9:15 AM, during an interview with the Administrator and the Director of Nursing (DON), the Administrator stated that the facility held quarterly Quality Assurance Performance Improvement (QAPI) meetings on the third Tuesday of the month during the months of January, April, July and October. [...]

Inspectors wroteBased on interviews and records review on 9/19/25, it was determined that the facility failed to ensure a resident (Resident #2) was free from a medication error when the medication nurse administered wrong medication to Resident #2; and the facility also failed to follow their policy for medication administration. The deficient practice was identified for 1 of 3 residents reviewed for medication administration. This was evidenced by the following. According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Type 2 Diabetes Mellitus, Respiratory Failure, Pneumonia and Toxic Effect of Tobacco Cigarettes. According to the Minimum Data Set (MDS), an assessment tool dated 07/25/2025, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the Resident was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 08/08/2024 from 09:24 AM until 10:00 AM, the surveyor observed the following in the kitchen in the presence of the Dietary Director #1 (DD#1): 1. The DD and the Food Service Worker (FSW#1) had facial hair and were not wearing beard guards. The DD#1 stated the beard guard is only used when on the line or direct handling of food. 2. In the walk-in freezer a frozen strawberry cream pie and a cookies and cream pie had no label and no date. The DD#1 stated it should be dated and he threw them away. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately assess the status of a resident in the Minimum Data Set (MDS), an assessment tool. This deficient practice was identified for 1 of 2 sampled residents reviewed for elopement (Resident #16) and was evidenced by the following: On 08/08/2024 at 10:00 AM, the surveyor observed Resident #16 in the bed with a wander guard/elopement alarm on his/her left ankle. According to the admission Record, Resident #16 was admitted to the facility with diagnoses including of but not limited to dementia and heart disease. Resident #16 had a Physician Order (PO) dated 02/18/2024 to apply a Wander guard to left ankle. A review of the admission MDS dated [DATE] for Resident # 16, indicated under Section P0200 for alarms was coded as 0 indicating there was no wander/elopement alarm. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to A.) reevaluate and update a resident-centered Care Plan (CP) upon readmission, to include the use of an anticoagulant, B.) failed to develop and implement a comprehensive person-centered care plan that include the use of an indwelling urinary catheter and use of a wander guard, and C.) failed to reevaluate and update a resident-centered CP to include actual skin impairment. The deficient practice was identified for 4 of 4 residents (Resident # 15, # 17, #43, # 3) reviewed for Care Plans. A.) On 08/08/2024 at 9:24 AM, Surveyor # 1 observed Resident #15 in bed. The resident responded when Surveyor # 1 spoke to them. The resident had covers over them and Surveyor # 1 was unable to observe the resident's skin. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to A.) ensure that a resident received appropriate treatment and services to prevent urinary tract infections (UTI) to the extent possible specifically by failing to clean and store a urinary catheter drainage bag according to facility policy and B.) failed to obtain a physician's order to flush an indwelling catheter (a tube inserted into the bladder to assist with emptying the bladder). The deficient practice was identified for 2 of 2 Residents (Resident # 17 and 42) investigated for Urinary Catheter or UTI. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed a.) to perform hand hygiene as indicated during wound care for 1 of 1 resident, (Resident # 265) reviewed for pressure ulcers, and b.) the facility failed to maintain a sanitary environment for 1 of 9 residents, (Resident # 3), observed for infection control. The deficient practice was evidenced by the following: a.) On 08/08/2024 at 09:50 AM, Resident # 265 was observed sleeping in bed. Resident # 265 was observed to be on an air mattress with a scoop overlay. A review of the admission Record revealed that Resident #265 was admitted with diagnoses including but not limited to, Unspecified Severe Protein-Calorie Malnutrition, and Chronic Atrial fibrillation (an irregular and often very rapid heart rhythm). [...]

Inspectors wroteBased on observation, interview and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 11/22/22 from 09:43 AM -11:09 AM, the surveyor toured the kitchen in the presence of the Director of Food and Beverage (DFB) and the Executive Chef (EC) and observed the following: 1. In the line refrigerator, there was one sealed clear bag containing tan oval patties, the DFB identified as hash browns, with no label, no use by or expiration date. The DFB stated there should have been a label and use by date then removed the bag from the refrigerator. 2. [...]

Inspectors wroteBased on interview and review of pertinent facility documents it was determined that the facility failed to ensure there was a consistent process for tracking and securing accurate documentation of the vaccination status of all contracted staff for Covid-19, a contagious respiratory infection. This deficient practice was evidenced by the following: A review of the covid vaccination status list reflected that all staff identified as contracted were not listed. On 11/30/22 at 10:59 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON stated Laboratory (lab) Technicians (LT) were considered contracted staff but were not on the contracted staff vaccination status list. The DON stated that she did not have copies of the vaccination status of the LTs but had confirmed with the lab company via email that all the contracted LTs were vaccinated. [...]