Harbor's Edge

Based on observation, staff interview, and facility documentation review, the facility staff failed to store food in accordance with professional standards for food safety in the main kitchen. The findings included:Multiple food packages and bulk food containers were opened without a label indicating an opened or used by date. A gallon container of milk was expired past the use by date and was accessible for distribution. On 2/2/2026 at 4:22 p.m. an initial tour of the main kitchen was conducted with dietary staff (other staff, OS #1 and OS #2) in the main kitchen. Prior to the kitchen tour, OS #1 was asked what the expectation of opened items (dry goods and refrigerated items) regarding labeling is. OS #1 verbalized all opened items should have an open date and used by date when the product is opened. The walk-in refrigerator revealed an open container of shallots in liquid and a container of left-over rigatoni had no label on the containers indicating a use by date. There was also an expired unopen gallon of 2% milk accessible for distribution dated 2/1/26. At this time OS #1…

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 staff interviews, clinical record review, and review of facility documents, the facility's staff failed to have a resident call system that consistently relayed calls directly to a staff member and/or to a centralized staff work area from each resident's bedside, toilet, and bathing area for 1 of 3 residents (Resident #1) in the survey sample. The findings included: Resident #1 was originally admitted to the facility from a local hospital on [DATE] for rehabilitation services after coronary artery bypass graft surgery. The admission diagnoses included coronary artery disease, hypotension, hyperlipidemia, chronic kidney disease, dysphagia, history of breast cancer, anxiety, depression, and obesity. Also, Resident #1 tested covid positive on [DATE]. The resident expired at the facility on [DATE] therefore a closed record review was conducted. The resident's Minimum Data Set (MDS) was not completed therefore the following information was obtained from the Nursing assessment dated [DATE]. The assessment…

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 staff interview and facility documentation review, the facility staff failed to implement their abuse policy regarding the screening of employees for 9 employees no reference checks were obtained and for 3 employees no sworn disclosure statements were obtained in a sample of 19 employee records reviewed. The findings included: On 8/11/22, a review of 19 employee files was conducted and revealed the following: 1. The facility staff failed to obtain employee References for nine employees. The employee record review revealed that 9 current employees did not have reference checks. Employee #1 hired on 10/11/21, employee #2 hired on 9/15/21, employee #3 hired on 12/08/21, employee #4 hired on 1/27/22, employee #5 hired on 2/28/22, employee #15 hired 4/20/22, employee #16 hired on 1/15/21, employee #17 hired on 4/18/22 and employee #18 hired on 8/01/21. 2. The facility staff failed to obtain Sworn Disclosure Statements for three employees: Employee #1 was hired on 10/11/21, employee #2 was hired on 9/15/21 and employee #3 was hired on 1/28/21. On 8/11/22 at approximately 4:50…

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 information gleamed during a closed record review and staff interviews, the facility staff failed to complete an accurate discharge Minimum Data Set (MDS) assessment for 1 of 22 residents (Resident #27), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 5/24/22 and discharged from the facility to the community 7/2/22. The discharge diagnoses included; right foot cellulites/septic arthritis, osteomyelitis and chronic kidney disease. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact. Review of the discharge MDS assessment dated [DATE] revealed the resident's discharge was planned (A0310G), and coded return not anticipated (A0310F) to an acute care hospital at (A2100). Resident #27 was selected by the Centers 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 staff interview and clinical record review, the facility's staff failed to ensure a resident who had elected hospice services, their written care plan included both the most recent hospice care plan as well as the facility's care plan for 1 of 22 residents (Resident #3), in the survey sample. The findings included: Resident #3 was originally admitted to the facility 1/3/22 and had never been discharged from the facility. The current diagnoses included; Afib, heart failure and stage 4 sacral pressure ulcer. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/25/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision making were moderately impaired. Review of Resident #3's clinical record revealed she was admitted into hospice services on 4/11/22 for chronic heart failure. A review of the care plan in the clinical record revealed a problem which read; (name of the resident) is receiving hospice care (began…

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 staff interview, clinical record review and facility document review, it was determined that facility staff failed to ensure that the Comprehensive Care Plan was developed within 7 (seven) days after completion of the admission assessment for 4 Residents (Resident #24, #19, #14,#17) of 18 residents in the survey sample. The findings included: 1. For Resident #24, the facility staff failed to develop a comprehensive person-centered care plan. Resident #24 was originally admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included but were not limited to, hypertension and atrial fibrillation. Resident #24's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 08/21/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #24 as requiring extensive assistance of 2 with bed…

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, staff interviews, and review of the facility's policy, the facility staff failed to ensure that food was prepared, distributed and served under sanitary conditions. The finding included: On 09/04/19 at approximately 11:10 AM an initial tour of the kitchen was conducted with Other Staff # 4. The following was observed during the tour: 2 - 4 lb containers of classic Hummus with use by date 9/01/19. (Located in the Walk-in refrigerator) 1 large pan of fresh salmon not dated or labeled. (Located in the walk-in refrigerator) 1 container of ranch dressing opened (1/2 filled) no opened date listed. (Located in the reach-in refrigerator) 3 loaves of bread found in dry storage with expiration dates of 8/31/19. The above findings were discussed with the Food Service Manager (FSD-Other Staff #2) on 09/05/19 at approximately 10:15 AM. She was asked what should have been done with the above concerns. The FSD stated, Anything expired should be discarded and Anything not labeled or dated should be. On 09/10/19 at approximately 3:44 PM a pre-exit interview was conducted with…

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 resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to have one (Resident #2) of 18 residents in the survey sample, attend quarterly person centered care plan meetings and failed to conduct quarterly care plan meetings. The findings included: Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses for Resident #2 included but not limited to, Acute Kidney Failure and Dementia with lewy bodies. The current Minimum Data Set (MDS), a quarterly revision with an Assessment Reference Date (ARD) of 06/14/19 coded the resident with a 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Resident #2 was coded as requiring extensive assistance requiring a two person physical assistance with toilet use, bathing, personal hygiene and bed mobility; requiring one person physical assist with transfers and dressing; and eating requiring set-up…

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 resident interview, staff interview, and clinical record review, the facility staff failed to convey comprehensive care plan goals for 1 of 18 residents (Resident #21), in the survey sample, after she was transferred to an acute care hospital on 8/27/19. The findings included: Resident #21 was originally admitted to the facility 8/7/19, and readmitted on [DATE], after an acute care hospital stay for an infection. The current diagnoses included, osteoarthritis and a pantalar fusion with use of an external fixator of the left ankle and foot. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/14/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with transfers, extensive assistance of one person with bed…

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 clinical record review, staff interview, and facility documentation review, the facility's staff failed to electronically transmit an encoded and completed discharge Minimum Data Set (MDS), assessment to the Centers for Medicare/Medicaid System (CMS), for 1 of 18 residents (Resident #1), in the survey sample. The findings included: Resident #1 was originally admitted to the facility 3/25/19, and was discharged from the facility to the community 4/12/19. The diagnoses included adult failure to thrive, age related physical abilities and asthma. The admission MDS assessment with an assessment reference date (ARD) of 4/1/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring supervision after set-up with locomotion, extensive assistance of two with bed mobility and transfers, extensive assistance with one dressing, eating, toileting, personal hygiene and…

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 staff interviews, facility document review and clinical record review, it was determined that facility staff failed to ensure that the resident assessment was accurately coded for 2 of 18 residents in the survey sample. The assessment inaccurately reflected Resident #33's discharge status; and the facility staff failed to accurately document the number of days that injections of Lovenox were received for Resident #19. The findings included: 1. Resident #33 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Stroke and Type 2 Diabetes Mellitus. Resident #33's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of [DATE] was coded with a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #33 as requiring extensive assistance of 1 with eating, toilet use and personal hygiene and extensive assistance of 2 with bed mobility, transfer and dressing. On…

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 clinical record review, staff interview and review of the facility's policy, the facility staff failed to ensure 1 of 18 residents in the survey sample (Resident #24) did not receive as needed anti anxiety medication Ativan for greater than 14 days without the physician and/or prescribing practitioner thoroughly evaluating the resident for the appropriateness of continuous as needed use and indication of the duration of use. The findings included: Resident #24 was originally admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included but were not limited to, hypertension and atrial fibrillation. Resident #24's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 08/21/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #24 as requiring extensive assistance of 2 with…

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 staff interviews the facility staff failed to use clean equipment and perform appropriate hand hygiene during wound care for 1 of 18 residents (Residents #27), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 8/10/19 and had not been discharged from the facility. The resident's diagnoses included; an abdominal surgical wound related to a ventral hernia causing a small bowel obstruction. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/17/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring supervision after set-up with eating and walking, supervision of one person with bathing, extensive assistance of one person with locomotion, limited assistance of one with bed mobility, dressing, toileting, and personal hygiene. In section M (Skin Condition)…

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.