Harvard Gardens Rehabilitation & Care Center

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure Resident #100 received all personal belongings upon discharge. This affected one resident (Resident #100) of three residents reviewed for discharge.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure resident use equipment and the physical environment were maintained in a safe, clean, sanitary, and well functioning condition. This deficient practice affected one resident (Resident #7) of three reviewed for physical environment and had the potential to affect all 105 residents residing in the facility.

Inspectors wroteBased on observation and resident and staff interviews, the facility failed to ensure foods were served at a palatable temperature. This affected five (Residents #5, #7, #30, #50, and #100) of five residents interviewed for palatable food and had the potential to affect all 102 residents who received meals prepared by the kitchen. The facility identified three (Residents #31, #58, and #59) as receiving no food by mouth (NPO). The facility census was 105.

Inspectors wroteBased on record review, observations, resident and staff interviews, review of dietary guidance from NephCure Kidney International and Kaiser Permanente, and facility policy review, the facility failed to ensure that therapeutic diet orders were accurately implemented for two residents (Residents #36 and #10) of three reviewed for therapeutic diets. The facility census was 105.

Inspectors wroteBased on medical record review, review of facility policy, review of informational articles from American Cancer Society, and interview the facility failed to develop and implement a system for identifying, monitoring, and caring for Resident #3's implanted venous access device (a port placed under the skin for use to administer intravenous treatments to mitigate risk for infection. This affected one resident (#3) of three residents reviewed for vascular access devices. The facility census was 102. Actual Harm occurred on 03/04/26 when Resident #3 was identified by a non-facility oncology nurse at an outside appointment to have a dressing to an implanted venous access device that was heavily soiled. [...]

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to maintain safety during assisted ambulation, resulting in a fall. This affected one resident (#57) of three residents reviewed for falls. The facility census was 102.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure residents' rights to privacy and confidentiality of their medical records were maintained. This had the potential to affect all 107 residents residing in the facility. The facility census was 107.

Inspectors wroteBased on review of staffing schedules and timecard punches, review of resident census data, and staff interview, the facility failed to ensure a registered nurse worked in the facility for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 107 residents residing in the facility. The census was 107.

Inspectors wroteBased on review of narcotic medication logs, medical record review, staff interview, and facility policy review, the facility failed to ensure all narcotic count sheets were signed, completed, and maintained the accurate receiving, dispensing, and reconciliation of all controlled substance medications, and failed to ensure administered medications were accurately documented within the medical record. This had the potential to affect all 107 residents residing in the facility. The facility census was 107.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure all hot foods were served at adequate and palatable temperatures. This had the potential to affect 105 residents who received meals from the facility. The facility identified Resident #8 and Resident #67 received no food from the kitchen. The facility census was 107.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the kitchen environment, kitchen equipment, and food was maintained in a clean and sanitary manner. This had the potential to affect 105 residents who received meals from the facility. The facility identified Resident #8 and Resident #67 who received no food from the kitchen. The facility census was 107.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure its dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all 107 residents residing in the facility. The facility census was 107.

Inspectors wroteBased on medical record review, business records review, and staff interview, the facility failed to ensure final accounting and conveyance of resident funds was completed within 30 days upon death. This affected three (#126, #127, and #128) of three residents reviewed for final conveyance of trust accounts. The facility census was 107.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the physical environment was maintained in a clean, sanitary, and homelike manner. This affected 28 (#17, #34, #37, #38, #39, #43, #47, #50, #52, #53, #54, #58, #63, #64, #74, #77, #81, #83, #86, #87, #90, #92, #98, #99, #104, #107, #141, and #162) of 107 residents residing in the facility. The census was 107. Findings Include:1. Observation of Resident #64's room on 02/25/26 at 11:46 A.M. revealed no bathroom door was present. Interview with Licensed Practical Nurse (LPN) #634 on 02/26/25 at 11:50 A.M. verified the lack of a bathroom door in Resident #64's room.2. Observation of the facility environment with Housekeeping Director #700 on 02/26/26 between 1:15 P.M. and 1:45 P.M. revealed the air vent in Resident #50's room was heavily rusted; [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately code resident Minimum Data Set (MDS) assessments. This affected nine (#11, #29, #32, #52, #53, #62, #64, #87, and #102) of 24 residents reviewed for MDS assessment accuracy. The facility census was 107.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure residents needs and preferences were met regarding appropriate linens on beds and maintaining bathing equipment for use to accommodate resident preference. This affected two residents (#105 and #22) of 13 residents reviewed for accommodation of needs. The facility census was 107.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after hospice services were discontinued for one resident (#3) of three residents reviewed for hospice services. The facility census was 107.

Inspectors wroteBased on observation, resident and staff interviews, medical record review, and facility policy, the facility failed to develop and effective means of communication for a resident who spoke limited English to ensure the resident was able to effectively communicate requests and needs. This affected one (#89) of 24 residents interviewed for the provision of care. The facility census was 107.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to label, date, or initial supplemental tube feeding containers to notify when the supplement was hung and by which staff as ordered. This affected one (#70) of two residents reviewed for tube feedings. The census was 107.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview, the facility failed to ensure a resident had active orders for use of supplemental oxygen. This affected one (#53) of one residents reviewed for respiratory care. The census was 107.

Inspectors wroteBased on medical record review, resident and staff interview, review of medication administration audit reports, and review of a facility policy, the facility failed to ensure pain medications were administered as ordered to effectively manage a resident's pain. This affected one (#11) of seven residents reviewed for medication administration. The facility census was 107.

Inspectors wroteBased on medical record review, resident and staff interview, and facility policy review, the facility failed to ensure residents were seen by a physician in a timely manner as required. This affected one (#89) of 24 sampled residents reviewed for physician visits. The facility census was 107.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to ensure timely dental care was provided to address resident needs. This affected one (#89) of 24 sampled residents observed for dental concerns. The facility census was 107.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to ensure complete and accurate documentation was maintained in resident medical records. This affected three (#2, #6, and #14) of four residents reviewed for accuracy of documentation. The facility census was 107.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure infection control practices were maintained for residents on enhanced barrier precautions and proper cleaning of bodily fluids was completed. This affected two (#1 and #99) of seven residents reviewed infection control practices. The facility census was 107.

Inspectors wroteBased on review of the facility assessment and staff interview, the facility failed to ensure the facility assessment contained all required information. This had the potential to affect all 107 residents residing in the facility. The facility census was 107.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #10 received timely medical intervention for an acute change in condition. Actual Harm occurred on 03/18/25 at 1:49 A.M. when Resident #10 complained of numbness of the right side of the body and requested to go to the hospital. However, the resident was not transferred to the hosptial until 03/18/25 at 4:08 A.M. Hospital documentation revealed the resident was admitted for a cerebrovascular accident due to intracerebral hemorrhage, ischemic stroke. The resident reported he had complaints of right-sided weakness approximately four days ago which he described as a heaviness to his upper and lower extremities. Resident #10 stated his weakness had not improved since the initial onset. The resident reported he suffered a fall yesterday because his leg gave out. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure Resident #10's responsible party was notified of a change in condition and transfer to hospital. This affected one resident (Resident #10) of three residents reveiwed for change in condition.

Inspectors wroteBased on medical record review, review of personnel files, review of witness statements, interviews, and review of facility policy, the facility failed to prevent staff to resident verbal abuse. This affected one resident (#28) of three reviewed for respect and dignity. The facility census was 87.

Inspectors wroteBased on medical record review, review of personnel files, review of witness statements, interviews, review of the facility's self-reported incidents (SRIs), and review of facility policy, the facility failed to effectively implement their policy on abuse in regard to the timely reporting of an allegation of abuse and conducting a thorough investigation of an allegation of abuse. This affected one resident (#28) of one reviewed for abuse. The facility census was 87.

Inspectors wroteBased on medical record review, review of personnel files, review of witness statements, interviews, review of the facility's self-reported incidents (SRIs), and review of facility policy, the facility failed to report an allegation of staff to resident verbal abuse to the proper authorities. This affected one resident (#28) of one reviewed for abuse. The facility census was 87.

Inspectors wroteBased on medical record review, review of personnel files, review of witness statements, interviews, review of the facility's self-reported incidents (SRIs), and review of facility policy, the facility failed to conduct a thorough investigation of an allegation of staff to resident verbal abuse. This affected one resident (#28) of one reviewed for abuse. The facility census was 87.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #31's incontinence care was provided timely. This affected one resident (Resident #31) out of three residents reviewed for incontinence care. The facility census was 87.

Inspectors wroteBased on observation, interview and review of the facility policy, the facility failed to assure expired medications were removed from the medications used for resident consumption. This had the potential to affect all 96 residents residing at the facility.

Inspectors wroteBased on observation, interview, record review, review of the manufacturer instructions, and review of the facility policy, the facility failed to maintain appropriate infection control practices when obtaining blood glucose levels via a glucometer. This affected three (Residents #83, #156 and #52) of three residents observed for blood sugar assessments via glucometer and had the potential to affect an additional 19 residents, Resident #2, #4, #7, #8, #11, #19, #24, #27, #28, #34, #36, #41, #61, #66, #72, #73, #105, #153, and #154 who were identified by the facility as receiving blood sugar checks via glucometer. In addition the facility failed to have a complete water management plan in place. This had the potential to affect all residents. The facility census was 96.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident concerns documented in the Resident Council Meeting Minutes for November and December 2024 were not altered or removed and failed to ensure concerns from the group meetings were acted upon. This affected Resident #2, #7, #16, #17, #19, #24, #30, #34, #42, #47, #51, #58, #61, #71, #72, #74, #76, #78, #95, #152, #155 and #160 who attended resident council meetings and/or expressed concerns related to call light response. This affected 21 of 96 facility residents and had the potential to affect all residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure all required notices of potential financial obligation were given to residents prior to the discontinuation of skilled services while using their Medicare Part A benefit. This affected two residents (62 and #107) of three residents (#62, #106, and #107) reviewed for appropriate beneficiary notices. The facility census was 96.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to conduct a quarterly care plan meeting for one resident, Resident #2, of three residents reviewed for care plan meetings. The facility census was 96.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #2 received range of motion and a palm guard or carrot after receiving therapy services for a left hand contracture. This affected one resident (Resident #2) of one resident reviewed for contractures. The facility census was 96.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the hydration needs of Resident #156 were met when water flushes were not administered via a percutaneous endoscopic gastrostomy (PEG) tube per the physician orders. This affected one of one resident reviewed for tube feedings, Resident #156. The facility census was 96.

Inspectors wroteBased on record review and interview the facility failed to ensure pharmacy recommendations were addressed. This affected one resident (#86) of five residents (#53, #69, #84, #86, and #156) reviewed for unnecessary medications. The facility census was 96.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure call lights were easily accessible and consistently in good working order. This affected five residents (#6, #7, #154, #155, and #156) of five residents reviewed for call lights.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to serve food in a manner to protect it from contamination. This had the potential to affect all residents residing in the facility. The census was 96.

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure a well maintained and comfortable environment. This affected seven (Residents #4, #6, #31, #38, #40, #58, and #86) of 29 residents residing on the second floor.

Inspectors wroteBased on record review, observations, policy review and interview, the facility failed to serve palatable meals at an appropriate temperature. This affected 11 (Resident #7, #20, #47, #53, #62, #64, #67, #69, #72, #76 and #82) of 96 residents residing in the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Resident #51was seen my a physician least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. This affected one resident (#51) of the three residents reviewed for physician visits. The facility census was 92.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure its kitchen area was maintained in a clean and sanitary manner. In addition, the facility did not ensure that food was plated to be served in a sanitary manner. This had the potential to affect all 94 residents receiving food from the kitchen. There were no residents residing in the facility not receiving food from the kitchen. Findings Include: Observation on 02/21/24 at 10:05 A.M. a tour of the kitchen was conducted with the Director of Nursing (DON). The floor had dirt and food buildup. There was also a buildup of dirt under the steam table where food was served from. The dirty floor was verified with the DON at the time of the tour. The inside of the drawer holding the serving and cooking utensils had dirt and grease buildup. The surface of the drawer had a greasy texture. [...]

Inspectors wroteBased on observation, interview and review of cleaning schedules, the facility did not ensure residents were sitting in clean wheelchairs. This affected four residents (#14, #15, #29 and #47) out of 66 residents utilizing wheelchairs. The facility census was 94.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, schedule review, and policy review the facility did not ensure sufficient nursing staff to provide nursing and related services to assure resident safety when two of four nurses left the building for lunch at 12:00 A.M. on 02/05/24 and did not return until 4:30 A.M. (4.5 hours). This had the potential to affect 37 residents (#2, #3, #4, #7, #10, #12, #13, #11, #18, #19, #28, #30, #34, #38, #44, #47, #49, #50, #52, #54, #53, #56, #57, #60, #62, #66, #70, #71, #76, #80, #81, #86, #88, #89, #93, #91, and #97) residing on the units assigned to the two nurses. The facility census was 94. Findings Include: A review of the facility assessment dated [DATE] revealed the facility will be staffed with three to four nurses per shift. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure Resident #54 received meals according to documented food preferences. This affected one resident (#54) of three residents investigated for food preferences. The facility census was 94. Findings Include: Record review for Resident #54 revealed an admission date of 02/05/24 with diagnoses including vascular dementia, depression, epilepsy, anxiety, diabetes mellitus type II, and hemiplegia following a cerebral vascular accident (CVA). Resident #54's diet orders included a regular diet with low concentrated sweets. Review of a dietary admission note dated 02/15/24 included Resident #54 disliked pork and ground meat. Review of the nurse practitioner notes dated 02/19/24 revealed Resident #54 does not eat pork or beef. The nurse practitioner instructed nursing to inform the kitchen. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide adequate supervision to prevent the elopement of a resident. This affected one (Resident #100) of one resident reviewed for elopement. The facility census was 99.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to prevent an in-house acquired pressure ulcer for Resident #14. Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, the area declined to a Stage IV pressure ulcer with odor noted with recommendation for hospitalization and possible amputation. This affected one resident (#14) of three residents reviewed for pressure ulcers. The facility census was 98.

Inspectors wroteBased on observation, interviews, facility policy review, and facility invoices, the facility failed to serve hot and palatable foods. This had the potential to affect all residents. The facility identified 97 of 98 residents that received food from the kitchen. Resident #5 was identified as receiving no food by mouth. The facility census was 98.

Inspectors wroteBased on observation and staff interview the facility failed to ensure foods were stored in a matter to prevent contamination. This had the potential to affect all residents. The facility identified 97 of 98 residents that received food from the kitchen. Resident #5 was identified as receiving no food by mouth. The facility census was 98.

Inspectors wroteBased on observation, record review, personnel file review, job description review, interview, review of a facility Legionella water management plan documentation, review of Centers for Disease Control and Prevention (CDC) guidance, review of facility self-reported incidents (SRI), and review of the Occupational Safety and Health Standards (OSHA) standards for safe oxygen storage the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Tthe facility failed to prevent an in-house acquired pressure ulcer for Resident #14. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 98 residents in the facility.

Inspectors wroteBased on observation, record review, facility policy review, review of a facility Legionella water management plan documentation, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to fully implement a complete water management program to prevent the growth of Legionella bacteria. In addition, the facility failed to maintain standard infection control protocols regarding isolation precautions. This had the potential to affect all 98 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, and facility floor plan review the facility failed to ensure its environment was maintained in a clean and sanitary manner. This affected 9 residents (#4, #14, #18, #23, #33, #46, #68, #76, and #77) with the potential to affect all residents. The facility census was 98.

Inspectors wroteBased on observation, interview, facility policy review, and review of the Occupational Safety and Health Standards (OSHA) standards for safe oxygen storage the facility failed to ensure oxygen tanks were stored and secured in a safe manner. This had the potential to affect all 98 residents in the facility.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure care plans were updated and accurate for Residents #7, #14, #35, #73, #80, #244 and #294. This affected seven residents (#7, #14, #35, #73, #80, #244 and #294) of 23 residents reviewed for assessments. The facility census was 98.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to obtain signed consents or declinations and evidence of education for influenza vaccinations for Residents #40 and #62. This affected two residents (#40 and #62) of six residents reviewed for immunizations.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to timely notify the physician and dietitian of Resident #294's continued refusal of daily weights. This affected one resident (#294) of four residents reviewed for weights. The facility census was 98.

Inspectors wroteBased on record review, staff interview, self-reported incident (SRI) review, and facility policy review, the facility failed to prevent resident-to-resident abuse. This affected one resident (Resident #81) of four residents reviewed for abuse. The facility census was 98. Findings Include: 1. Resident #81 was admitted to the facility on [DATE] with diagnoses including depression, bipolar disorder, psychotic disorder with delusions, and schizophrenia. The resident resides on the facility's secured unit. Review of the comprehensive admission minimum data set (MDS) assessment dated [DATE] revealed Resident #81 was moderately cognitively impaired, exhibited no behaviors during the assessment period, and was non-ambulatory. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to implement their abuse policy regarding an allegation of resident-to-resident abuse. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to report an allegation of resident-to-resident abuse to the state agency within the required time frames. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to investigate an allegation of resident-to-resident abuse. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to develop care plans regarding behaviors and medications usage. This affected three residents (#55, #73, and #68) of four residents reviewed for behaviors and psychotropic medications. The facility census was 98.

Inspectors wroteBased on record reviews, interviews, and facility policy review the facility failed to adequately monitor Resident #90 after a significant change in condition and failed to follow physician orders for daily weights for Resident #294. This affected one resident (#90) out of three residents reviewed for death and one resident (#294) of four residents reviewed for weights. The facility census was 98.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed eliminate risk hazards when a staff member pushing a dietary cart ran into Resident #90 causing the resident to fall out of her wheelchair. This affected one resident (#90) of three residents reviewed for falls. The facility census was 98.

Inspectors wroteBased on observation, record review, resident and staff interviews, and facility policy review the facility failed to ensure timely colostomy care was provided. This affected one resident (#14) of one resident observed for colostomy. The facility identified two residents (#10 and #14) with colostomies. The facility census was 98.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #50. This affected one resident (#50) of one resident reviewed for dialysis. The facility census was 98.

Inspectors wroteBased on record review, staff interview, self-reported incident (SRI) review, and facility policy review the facility failed to implement interventions to attain or maintain a resident's highest practicable psychosocial well-being. This affected one resident (#73) of four residents reviewed for behaviors. The facility census was 98.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of pain medication for Resident #80. This affected one resident (#80) of five residents reviewed for unnecessary medication use. The facility census was 98.

Inspectors wroteBased on observation, staff interview, record review, and facility invoices, the facility failed to ensure the facility, including the kitchen and resident rooms, was free from pests (ants, flies, and gnats/fruit flies). This affected the kitchen and three residents' rooms (#4, #23, and #46). The facility census was 98.