Harbour Health Center

Based on observation, record review, resident and staff interviews, the facility failed to ensure 1 (Resident #7) of 3 residents reviewed, received care and services in accordance with the care plan and physician's orders to maintain skin integrity.The findings included:Review of the clinical record for Resident #7 revealed a readmission date of 6/8/23. Diagnoses included dementia, heart failure and type 2 diabetes.The Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/15/26 revealed Resident #7 scored 13 on the Brief Interview for Mental Status, indicating intact cognition.The care plan initiated on 6/12/23 and revised on 12/08/25 revealed Resident #7 had a potential for impaired skin integrity related to impaired mobility, fragile skin, diabetes, neuropathy (damage to peripheral nerves), edema (swelling), impaired cognition, incontinence. The care plan noted that Resident #7 has a history of noncompliance with Geri sleeve (protective sleeve).On 10/7/25, the care plan was updated to reflect a skin tear to the resident's left hand and on 12/8/25, a skin tear to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure the medical record for 1 (Resident #1) of 3 residents reviewed was complete by failing to safeguard medical record information against destruction.The findings included:Review of the facility's policy and procedure titled, admission Assessment and Follow Up: Role of the Nurse revealed the steps in the procedure included, .Reconcile the list of medications from the medication history, admitting orders, the previous Medication Administration Record (if available), and the discharge summary from the previous institution, according to established procedures. 12) Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders. Documentation: The following information should be recorded in the resident's medical record: 5) Orders obtained from the physician; 6) the signature and title of the person recording the data.Review of the facility's Policy titled, Retention of Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to protect the resident(s') right to be free from neglect when it failed: 1) to provide to structural processes necessary to ensure ongoing incontinence care to two residents (#1 and #2); and 2.) to prevent emotional anguish to 1 resident (#2). The findings included: Record Review of Abuse and Neglect-Clinical Protocol Policy last revised in March 2018 stated that neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Record Review of ADL Policy, last revised on March 2018 stated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, as a result of a facility's investigation, when an alleged violation was verified, the facility failed to take appropriate corrective action to protect residents and oversee the implementation of corrective action and evaluate whether it is effective for 2 of 2 incidents reported by the facility. The findings included: On 10/30/24, the facility reported an investigation into 19 possible instances of drug diversion regarding prescribed, as needed, pain medications. During the investigation, the facility interviewed staff and residents, in-serviced staff on misappropriation of property, and discussed the incident in a Quality Assurance Performance Improvement (QAPI) meeting on 11/20/24. The facility investigation concluded that they could not verify any medications were diverted but did verify documentation was incomplete in 19 instances involving 9 separate residents' as needed pain medications. Staff members involved was subsequently terminated. There was no further actions taken to verify this action was effective. On 2/20/25, the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure incontinence care was provided to 2 residents (#1 and #2). The findings included: Record review of the Activities of Daily Living (ADL) Policy, last revised on March 2018 said, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, including Hygiene (bathing, dressing, grooming, and oral care). Resident #1 was admitted to the facility on [DATE] for skilled nursing care. Resident #1 has a diagnosis of Alzheimer's disease, impaired gait and mobility, and generalized muscle weakness. Resident #1 requires staff assistance with hygiene care and transfers in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure they posted and updated the nurse staffing information with the facility name and an updated census per shift. The facility further failed to maintain the nursing staffing information for 18 months. The findings included: On 2/5/24 at 9:10 a.m. via observation, the nurse staffing information form dated 2/5/24 located in the main lobby did not have the facility's name and the current census. On 2/5/24 at 4:00 p.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/05/24. On 2/06/24 at 10:10 a.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/06/24. On 2/06/24 at 4:10 p.m. via…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff, resident and family interview, the facility failed to ensure 2 (Residents #12, #29) of 4 residents reviewed received care and services in accordance with professional standards, by failing to implement physician's orders for protective skin sleeves. The findings included: 1. Clinical record review revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included Dementia. The physician order effective 10/22/23 included to apply Geri-sleeves (protective sleeves) to both arms for protection. The Care Plan initiated 5/27/21 documented Resident #29, has the potential for impaired skin integrity r/t (related to) impaired cognition, impaired mobility, anorexia, incontinence, malnutrition. The resident needs assistance to apply protective garments; Geri-sleeves to BUE (bilateral upper extremities). On 2/5/24 at 1:56 p.m., 2:51p.m., and on 2/6/24 at 8:45 a.m., Resident #29 was observed in the activity area wearing a short sleeve shirt without Geri-sleeves as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to ensure 1 (Resident #29) of 1 dependent resident received the appropriate assistance to apply corrective lenses as per the physician's orders and care plan to maintain vision. The findings included: Review of the clinical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included Dementia and unspecified age-related cataract. The physician's orders dated 6/30/21 included for the nurse to verify the resident's glasses were on in the morning and remove the glasses at bedtime. The Care Plan revised on 7/1/2021 noted Resident #29 had impaired visual function related to cataracts and used glasses. The interventions included to remind the resident to wear glasses when up. Assist with placing glasses on in the morning, remove at bedtime. The Quarterly Minimum Data Set (MDS) assessment with a target date of 12/7/23 indicated the resident's vision was adequate with corrective lenses. The care plan summary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, clinical records review and facility policy review the facility failed to follow physician's ordered fluid restrictions for 1 (Resident #14) of 2 residents reviewed for hydration management. The findings included: Review of facility policy titled Encouraging and Restricting Fluids, revised October 2010 which stated, Purpose: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Preparation: 1. Verify that there is a physician's order for this procedure . General Guidelines: 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake. 3. Record fluid intake on the intake side of the intake and output record. Record fluid intake in ml (milliliter) . 8. Be sure an intake and output record is maintained in the resident's room . Documentation: . 6. The amount (in mLs) of fluids consumed by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview the facility failed to ensure its medication error rate remained below 5%. Four licensed nurses with 27 opportunities were observed. Two medication errors were identified resulting in a 7.41% error rate. The findings included: Policies and Procedures titled Administering Medications (reviewed/revised April 2019), specified Medications are administered in a safe and timely manner, and as prescribed. The policy states 4. Medications are administered in accordance with prescriber orders, including any required time frame. On 2/7/24 at 9:01 a.m., Licensed Practical Nurse (LPN) Staff D was observed administering two medications to Resident #23, including Entresto and metoprolol. The physician's orders specified to hold the medications if the systolic blood pressure was less than110 or the heart rate was less than 65 beats per minute. Resident #23 had a heart rate of 60 beats per minute. This indicates the medication should be held per the physician order parameters. On 2/7/24 at 10:50 a.m., in an interview LPN Staff D verified the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

On 2/06/24 10:08 a.m. the medication storage room C wing checked with the Assistant Director of Nursing (ADON). During the observation a large white oval pill was found in the sink. Internet search shows it is Metformin (a pill to control blood sugar). Photographic evidence obtained. During an interview on 2/6/24 at 10:09 a.m. ADON stated that she did not know what the large white pill was and she acknowledged that it should not be in the sink in the medication room. On 2/06/24 at 11:25 a.m., LPN Staff Q's medication cart C left was checked and found to have opened over the counter (OTC) liquid medication not labeled with the open date. LPN staff Q confirmed 3 of the bottles did not have an open date on them and she could not know how long they had been in the drawer open. The following medication bottles were observed not dated with open date. -Geri-tussin DM -Liquid pain relief acetaminophen -Iron supplement During an interview on 02/07/24 at 11:45 a.m. the Director of Nursing (DON) stated that her expectation was for nurses when opening OTC liquid medication is to place an open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, the facility failed to ensure a monthly Medication Regimen Review (MRR) for 2 (#24 and #61) of 5 residents reviewed. The findings included: The facility Policy for Medication Regimen Review (MRR) with an effective date of 12/1/07 noted, The Consultant Pharmacist will conduct MMRs if required under a Pharmacy Consultant Agreement . The facility should maintain copies of MRRs on file in the facility, either as part of the resident's permanent medical record or in a special file, in accordance with applicable law. Review of the clinical records showed Resident's #24 and #61 were admitted to the facility respectively on 6/12/20 and 3/19/21. The clinical records lacked documentation of a medication regimen review for September 2021. Review of the Consultant Pharmacy Reports for September 2021 showed MRRs were conducted for 17 residents without recommendation and for two residents with recommendations. Residents #24 and #61 were not included in the MMRs. Review of the facility Detailed Census Report for September 2021 showed there were between 84…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interview the facility failed to administer medications according to the physician's orders for 1 (Resident #283) of 5 residents observed for medication administration. Three Licensed nurses and 25 opportunities were observed. Two medication errors were identified resulting in an 8% error rate. The findings included: The facility's Instructional Guidelines Manual for Medication Administration revised 08/05/2015 reads, . All medications must be ordered by the Physician . Administer medications within a two (2) hour time frame (one hour before to one hour after the time prescribed by the physician) . When administering medications, always check for the six R's. Right resident, right medications, right time, right route, right dosage, right documentation . On 3/7/22 at 12:00 p.m., Licensed Practical Nurse (LPN) Staff A was observed administering seven (7) different medications to Resident #283, including one tablet of Metoprolol 25 milligrams Extended Release and one tablet of Cefdinir 300 milligrams. The physician's orders dated 3/2/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, staff and resident interviews, the facility failed to ensure proper storage of medications for 1 (Resident #7) of 1 resident observed with unsecured prescribed eye drops at the bedside. The findings included: Review of the Policy and Procedure for Storage and Expiration of Medication, Biological, Syringes and Needles with an effective of 12/1/07 (revised 1/1/13) documented . Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked/cabinet/cart or locked medication room that is inaccessible by residents and visitors . Facility should store bedside medications or biologicals in a locked compartment within the resident's room . On 3/9/22 at 9:30 a.m., observed a bottle of Dorzolamide HCL eye drops and a bottle of Timolol Maleate eye drops stored in an empty tissue box on Resident #7's overbed table. In an interview at the time of the observation Resident #7 said she has been using the drops for years and sometimes the nurses just leave the medications in her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.