Complete Care at Harston Hall LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Harston Hall LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF602Aug 15, 2024

  Based on the review of clinical records, facility policies and procedures, resident's financial information, facility investigation and resident and staff interviews, it was determined that the facility failed to ensure that the residents where free from misappropriation and exploitation of property related to the unauthorized access of Resident R1's financial information, theft of money from resident's bank account, unauthorized purchase on resident's account, and receiving monetary assistance by the facility staff. Facility staff failed to report the alleged violation in a timely manner. This failure resulted in an Immediate Jeopardy situation to Resident R1 who experienced financial loss, mental health decline, and psychosocial harm for one of three residents reviewed. […]

• Immediate jeopardy, isolatedF609Aug 15, 2024

  Based on staff interviews, clinical record review, and policy review, it was determined that the facility failed to ensure an allegation of exploitation of resident's property was reported to the facility's Nursing Home Administrator in accordance with requirements. The facility failed to protect one of three sampled residents (Resident R1) from exploitation of resident's property by three perpetrators which resulted in an Immediate Jeopardy situation to Resident R1 who experienced financial loss, mental health decline, and psychosocial harm. This was identified as past non-compliance. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2025

  Based on observations of the food and nutrition services department, it was determined that foods were not being stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: Observations on March 22, 2025 of the main kitchen where foods and beverages were stored, prepared and assembled for distribution and service to the residents revealed that the low temperature dish machine was not fully functioning since March 14, 2025. The director of dietary service could not demonstrate with the use of litmus test strip that the hypochlorite was registering an acceptable 50 ppm (parts per million) to effectively sanitize the dishes, utencils, pots, pans, cups, bowls, plates and trays for resident and dietary staff use. […]

• No harm, potential for more than minimal, widespreadF812Sep 21, 2023

  Based on review of facility policy, observation, and interview with staff, it was determined that the facility did not ensure that food was stored, in accordance with professional standards for food service safety. Findings include: Review of facility policy on food storage revealed that under section Policy Statement: All time/Temperature Control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with the guidelines of the FDA (Food and Drug Administration) Food Code. Under section Procedures: #2. All perishable food will be maintained at a temperature of 41 degrees Fahrenheit or below, except during necessary periods of preparation and service. #4. An accurate thermometer will be kept in each refrigerator and freezer. […]

• No harm, potential for more than minimal, widespreadF812Nov 21, 2022

  Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: An initial tour of the Food Service Department conducted on [DATE], at 10:15 a.m. with Employee E9, Food Service Supervisor, and Employee E8, Food Service Director (FSD), revealed the following: Observation in the receiving area revealed There were twelve wooden pallets stacked against the wall of the building, approximately 20 crates of expired water stacked outside the receiving door, multiple plastic bread racks and milk crates scattered near the outside the receiving door and a large metal rack leaning against the wall outside the door. […]