Harbor Health & Rehab

In the surveyor’s words

From the most serious findings on record at Harbor Health & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Jul 28, 2023

  Based on record review and interview, the facility failed to ensure a resident only received food in the form ordered by the physician related to the consumption of a regular donut during a transport which led to a choking incident and resulted in respiratory failure, cardiac arrest and ultimately his demise for 1 of 3 resident reviewed for mechanically altered diets. (Resident B) The immediate jeopardy began on [DATE] when the Administrator fed Resident B a regular donut, not in pureed form, which he consumed during a facility transport. Soon after, he turned blue, started choking and the Heimlich maneuver was performed. He then stopped breathing, CPR was initiated, and he was transferred to the hospital. […]

• Actual harm, isolatedF689Aug 9, 2024

  Based on record review and interview, the facility failed to ensure a dependent resident received adequate assistance and supervision to prevent accidents related to only one staff person assisting during a mechanical lift transfer for 1 of 2 residents reviewed for falls. (Resident 3) This deficient practice resulted in the resident falling and receiving a fracture to her leg. The deficient practice was corrected on 7/22/24, prior to the start of the survey, and was therefore past noncompliance. […]

• Actual harm, isolatedF684Jul 28, 2023

  Based on observation, record review, and interview, the facility failed to ensure a resident was monitored for signs and symptoms of constipation. The lack of assessment and monitoring resulted in the resident being hospitalized with a severe fecal impaction for 1 of 1 residents reviewed for constipation. (Resident 60) The facility also failed to ensure a fall follow up assessment was completed and an assessment including vital signs was documented prior to hospitalization for 1 of 2 residents reviewed for falls and 2 of 3 residents reviewed for hospitalization . (Residents E and 12) Findings include: 1. During an interview on 7/24/23 at 10:12 a.m., Resident 60 indicated he has horrible constipation issues and sometimes only has 1 bowel movement a week. […]

• No harm, potential for more than minimal, widespreadF851Dec 17, 2025

  Based on record review and interview, the facility failed to ensure the mandatory submission of staffing information, based on payroll data, was electronically submitted to iQIES. This had the potential to affect the 70 residents who resided in the facility. Finding includes: Nurse Staffing information was reviewed on 12/16/25 at 3:30 p.m. The CMS Payroll Based Journal (PBJ) Staffing Data report for FY Quarter 4 2025 indicated the facility failed to submit data.During an interview on 12/16/25 at 4:20 p.m., the [NAME] President (VP) of Operations indicated he was able to pull up the submission log of PBJ for the 4th quarter for the facility. The information from iQIES indicated there was a connection error and files failed to send. […]

• No harm, potential for more than minimal, widespreadF812Jul 28, 2023

  Based on observation and interview, the facility failed to store and prepare food under sanitary conditions related to built up grease on the stove top, open food containers, and uncovered food in the freezer for 1 of 1 kitchens observed. This had the potential to affect the 64 residents who received food from the kitchen. (The Main Kitchen) Findings include: During the initial kitchen tour on 7/24/23 at 8:50 a.m., with the Dietary Manager, the following was observed: a. The stove top and fire irons had a build up of grease. b. The dry food storage area had an open container of dry oats on the floor and an open container of grape jelly on the counter. c. […]