Harbor Hill Center

In the surveyor’s words

From the most serious findings on record at Harbor Hill Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 30, 2025

  Based on record review and interview, the facility failed to ensure safe transfer practices implement clear, consistent transfer instructions for 1 of 2 residents reviewed for falls. The failure resulted in Resident #5 being transferred with an inappropriate device, inconsistent with therapy recommendations, which contributed to a fall-related injury requiring hospitalization and surgical intervention. Findings:Review of an incident report dated 11/15/25 indicated that at approximately 6:30 a.m. staff attempted to transfer Resident #5 with a sit-to-stand lift. During the transfer, the resident's foot slipped from the lift platform, and staff were unable to safely reposition the foot. The resident was lowered to the floor. […]

• No harm, potential for more than minimal, widespreadF730Jan 14, 2026

  Based on interview, the facility failed to complete annual performance evaluations at least every 12 months for 5 of 5 sampled employees (Certified Nursing Assistant #1 [CNA1] CNA2, CNA3, CNA4, CNA5). Finding:On 01/14/226, at 11:00, the last two performance evaluations were requested for five Certified Nurse Assistance (CNA 1-5). On 1/14/26 at 11:30 a.m., in an interview with the surveyor, the Administrator stated that the 5 C.N.A.'s that were requested have not had a performance evaluation for the past two years.

• No harm, potential for more than minimal, patternF583Jan 14, 2026

  Based on observations and interviews, the facility failed to ensure the privacy and confidentiality of residents by displaying video camera/monitors at the nurses station that staff, family, visitors and other residents could view and failed to obtain an order for use of a video camera/monitors, or consent from residents and/or resident representatives prior to use of a video camera/monitor for 2 of 2 residents reviewed (Resident #8 [R8] and R2).Findings: Findings: On 1/12/26 at 12:18 p.m., during an initial tour of the Long Term Care unit Fort Point, a surveyor observed 2 video camera/monitors on the nurses station desk in view of staff, family, visitors, and other residents. […]

• No harm, potential for more than minimal, patternF584Jan 14, 2026

  Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment for 3 of 3 days of survey (1/12/26, 1/13/26, and 1/14/26).Findings:On 1/12/26 at 12:24 p.m., a surveyor observed in room [ROOM NUMBER], the wall at the head of bed 1 and the bedside cabinet were heavily soiled with dried fluid residues. Both bedside tables in room [ROOM NUMBER] were observed to be heavily soiled with food debris prior to the lunch service.On 1/13/26 at 10:44 a.m., during an observation of the laundry department, a surveyor observed Laundry Staff folding clean linens. A face cloth was observed laying on the floor below the basket. […]

• No harm, potential for more than minimal, patternF880Jan 14, 2026

  Based on observations, facility policy reviews, and interviews, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for 2 of 3 days of survey by failing to ensure staff utilize proper personal protective equipment (PPE) in an Enhanced Barrier Precaution (EBP) room and failing to ensure staff washed their hands after handling soiled linens and touching multiple surfaces (1/13/26 and 1/14/26). Findings: On 1/12/26 a review of R8's clinical record was completed. In the Physician order section, it indicated R8 had treatments to open wounds on his/her coccyx and on the right and left heel (pressure ulcers) A review of the Facilities Enhanced Barrier Precautions with a revised date of 5/1/25. […]