Complete Care at Harrington Court

In the surveyor’s words

From the most serious findings on record at Complete Care at Harrington Court, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Mar 26, 2026

  Based on clinical record review, interviews, and facility document review, the facility failed to ensure that medication orders were accurately transcribed and verified for one (1) of two (2) residents reviewed for medication administration (Resident #1), resulting in a significant medication error when Methotrexate, ordered to be administered one time per week, was incorrectly transcribed and administered daily for nine (9) consecutive days. The error was not detected through required reconciliation processes, including RN transcription, supervisory second check, APRN review, physician review, and pharmacy consultant review, despite active MAR dose warnings. […]

• Actual harm, isolatedF697Jul 14, 2026

  Based on review of the clinical record, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for suicidal ideation, the facility failed to ensure that when Resident #1 continued to experience pain after administration of scheduled analgesics, licensed nursing staff assessed the ongoing pain and implemented available interventions, including review of the Medication Administration Record (MAR) and timely administration of ordered PRN pain medication. As a result, Resident #1's pain remained unrelieved, contributing to the escalation of distress and self harm behaviors. […]

• No harm, potential for more than minimal, patternF600Mar 28, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of thirteen (13) residents (Resident #1 and Resident #10) reviewed for abuse, the facility failed to ensure the residents were free from abuse. The findings include: 1. Resident #1's diagnoses included cerebral infarction (when blood flow to the brain is interrupted, causing brain tissue damage), legal blindness, anxiety disorder and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required moderate assistance with bed mobility and transfers. […]

• No harm, potential for more than minimal, patternF602Oct 28, 2024

  Based on review of the clinical record, facility documentation, facility policy and interviews for four (4) of nine (9) residents (Residents #1, 2, 3 and 4) reviewed for misappropriation, the facility failed to prevent the misappropriation of the residents' controlled narcotic medications. The findings include: 1. Resident #1's diagnoses included chronic pain syndrome, low back pain and polyneuropathy (damage of the peripheral nerves, affecting the skin, muscles and organs). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition, frequently experienced moderate pain and was independent with eating, transfers and ambulation. […]

• No harm, potential for more than minimal, patternF804Jul 13, 2023

  Based on observations of the dietary tray line, and review of facility documentation and interview, the facility failed to provide food at an appetizing temperature and failed to indicate holding temperature of sweet potatoes. The findings included: 1a. Observation of the dietary tray line and a test tray with Food Service Director of the lunch meal on 7/11/23 began at 11:23 AM identified the last cart left the kitchen at 12:46 PM and arrived at 600's wing at 12:48 PM, serving began at 12:52 PM, and the last resident tray was served to Resident #32 at 1:04 PM. […]