Harlan Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure it had safe drinking water available when there was a loss of normal water supply for all residents. This had the ability to affect all 132 residents. The findings include: In an interview with the Administrator, on 03/20/2025 at 11:10 AM, she stated the facility did not have a policy to address the availability of water when there was a loss of normal water supply. Further, she stated it was her expectation that the facility would have drinkable water available each day for a period of three days, for the residents consumption. Review of the facility's Water Utility Agreement, dated 12/21/2017, revealed the city's Municipal Water Works assisted the facility with emergency water access. Review of the facility's Emergency Preparedness Plan document, dated 03/17/2025, from the Food Service Vendor, revealed the industry standard was to have 1.5 gallons of water per person, per day, available in the event of an emergency. Observation on 03/19/2025 at 2:15 PM revealed the facility had a total of 1,368…

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, interview, record review, and review of the facility's policy, the facility failed to provide Notice of Medicare Non-Coverage (NOMNC) to residents before their coverage ended. Two of 10 residents reviewed (Residents (R) 282 and 279) revealed the NOMNC's were issued after the residents' benefits ended. The findings include: Review of the facility's policy titled, Notice Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS [Centers for Medicare and Medicaid Services]-10123, undated, revealed The NOMNC must be delivered to all Medicare beneficiaries at least two calendar days before Medicare covered services ended or the second to last day of service if care was not being provided daily. 1. Review of R282's NOMNC revealed the resident's Medicare coverage ended on 12/07/2024. Further review revealed Family Member (FM) 10 signed the NOMNC on 12/09/2024 which was two days after the resident's coverage ended. During an interview with the Business Office Manager 1 (BOM1) on 03/21/2025 at 9:19 AM, she stated she called FM10 and informed her of R282's…

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, interview, record review, and review of the facility's policy, the facility failed to ensure each resident received food and drinks which were palatable, attractive, and at a safe and appetizing temperature for five of 35 sampled residents reviewed for food temperatures (Residents (R)19, R67, R86, R98, and R111). During resident council, residents expressed concerns of their food being served cold when the aides passed their trays. Observation of the breakfast meal, on 03/19/2025, revealed the sausage, eggs, biscuits, oatmeal, milk, and cranberry juice were not at an appetizing and acceptable temperature. Observation of the breakfast meal, on 03/20/2025, revealed the sausage, eggs, oatmeal, and grape juice were not at an appetizing and acceptable temperature. The findings include: Review of the facility's policy titled, Dietary Infection Control, undated, revealed temperatures must be maintained at 41 degrees (41°) Fahrenheit (F) or below for cold or refrigerated food. Further review revealed temperatures must be maintained at the following Fahrenheit settings:…

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, interview, and review of the facility's policy, the facility failed to serve food in accordance with professional standards for food service safety. The census was 132. The findings include: Review of the facility's policy titled, Tray Line and Meal Delivery Service, undated, revealed staff were to not touch the food surface areas of plates, bowls, cups, or saucers. Staff were to pick the items up by the outer rim only. Continued review revealed staff were to use tongs, spoons, scoops, etc. to serve all food including bread. Additionally, staff should wash their hands and change gloves between each task. Review of the facility's policy titled, Hand Washing, undated, revealed staff were to wash their hands after handling soiled equipment or utensils and during food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks. Observation on 03/17/2025 at 4:15 PM revealed Cook1 touched the surface area of plates as she removed them from the plate warmer. Further observation revealed she rested 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan (CCP) for one (1) of eleven (11) sampled residents (Resident #8). On [DATE] Resident #8 was rolled out of the bed, onto the floor, by State Registered Nursing Assistant (SRNA) #1, while providing care unassisted by another staff member. Resident #8 was care planned to be a two person staff assist for Activities of Daily Living (ADL's). The findings include: Review of the facility's policy, titled Care Plan Policy and Protocol, revised 09/2017, revealed the facility would develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs that are identified in the comprehensive assessment. Further review of the policy revealed the [NAME] would be utilized as a guide for nurse aides in providing care on a daily basis. Continued review of the policy…

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 interview, record review, and facility policy, it was determined the facility failed to ensure residents received appropriate supervision for one (1) of eleven (11) sampled residents (Resident #8). On [DATE] Resident #8 was rolled out of the bed, onto the floor, by State Registered Nursing Assistant (SRNA) #1, while providing care unassisted by another staff member. The findings include: Review of the facility's policy, titled Falls Management/Prevention, revised 06/2021, revealed it was the policy of the facility to screen all residents to identify possible risk factors that may place a resident at risk for falls, to evaluate those risks, implement interventions to reduce those risks and observe those interventions and modify when necessary. Further review of the policy revealed it was the policy of the facility to investigate any resident fall to determine root cause and appropriate interventions to put in place to minimize the risk of recurrence and the risk of injury related to a fall. Review of…

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, interview, and facility policy review, it was determined the facility failed to label and store biologicals with currently accepted professional principles for one (1) of five (5) medication carts observed. Four (4) multi-dose vials of Insulin which were not dated when opened were observed on one (1) medication cart on the west wing. In addition, one of the vials of insulin did not have a pharmacy label which included the resident's name, medication name, dose, route, etc. The findings include: Review of the facility's policy titled, Protocol for Multi-Dose Vials, undated, revealed multi dose vials should be initialed and dated when opened and stored per manufacturers recommendations. Further review of the policy and review of the manufacturers recommendations revealed multi-dose vials of insulin will be discarded after twenty eight (28) days. Observation on 04/15/2021 at 3:59 PM of the west wing medication cart (for the 900 hallway) revealed two (2) ten (10) milliliter (ml) multi dose bottles of Novolog 70/30 Insulin, one (1) ten (10) ml multi dose bottle of…

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, interview, record review, and facility policy review it was determined the facility failed to develop and implement person-centered comprehensive care plans for one (1) of two (2) residents (Resident #41) related to hospice care and one (1) of four (4) residents (Resident #43) related to oxygen therapy. The findings include: Review of the facility policy titled, Care Plan Policy and Protocol, revised September 2017, revealed the facility would develop a comprehensive care plan for each resident which would include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the resident's comprehensive assessment. 1. Review of Resident #41's medical record revealed the facility admitted the resident on 04/14/16 with diagnoses including Cerebral Infarction, Fatigue, Depression, Dysphagia, Dementia, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Hemiplegia. Review of Resident #41's Minimum Data Set (MDS)…

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, interview, medical record review, and review of the facility's policy, it was determined the facility failed to ensure two (2) of four (4) sampled residents (Resident #43 and Resident #123) who had physician orders to receive oxygen therapy were provided services as ordered by the physician. Review of physician orders for Resident #43 revealed an order for oxygen at two (2) liters per minute (LPM); however, observations of Resident #43 on 03/12/19 and 03/13/19 revealed the resident was not wearing the oxygen. Review of the physician's orders for Resident #123 revealed an order for the resident to receive oxygen at three (3) liters per minute via nasal cannula continuously. However, observations of Resident #123 on 03/12/19 revealed the resident's nasal cannula was observed to be on the floor. 1. Review of Resident #43's medical record revealed the facility admitted the resident on 02/18/14 with diagnoses of Black Lung Disease, Coronary Artery Disease, Congestive Heart Failure, Emphysema,…

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.