Harbor Lakes Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Harbor Lakes Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 15, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure kitchen staff followed proper hand hygiene during meal preparations. This failure could place residents that eat out of the kitchen at risk for food borne illness and cross-contamination. Findings include: During an observation and interview on 08/13/2024 at 11:02 AM, DA-D was observed chopping lettuce and placing it into the plastic bag with her bare hands. DA-D stated she was supposed to have had gloves on when handling food. She stated in not doing so, could have possibly contaminated residents' food and made them sick. […]

• No harm, potential for more than minimal, patternF657Aug 15, 2024

  48883 Based on observation, interview, and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment for 3 (Resident #9, Resident #15, and Resident #75) of 20 residents reviewed for comprehensive care plans. 1. The facility failed to ensure the interdisciplinary team reviewed and revised the plan of care quarterly for Residents #9 between 11/22/2023 & 06/19/2024. 2.The facility failed to ensure the interdisciplinary team updated the care plan after Resident #9's foley catheter was ordered on 07/16/2024. 3. The facility failed to ensure the interdisciplinary team reviewed and revised the plan of care quarterly for Resident #15 between 11/08/2023 & 07/17/2024. 4. […]

• No harm, potential for more than minimal, patternF804Aug 15, 2024

  44728 Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature as evidenced by a sample tray tested on [DATE]. This failure could affect the residents who ate food from the facility's kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served. The findings included: During an observation and interview on 08/13/2024 at 12:46 PM, the test tray was placed on the hall cart for transport. […]

• No harm, potential for more than minimal, patternF880Aug 15, 2024

  Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for staff members (CMA H, LVN A, CNA J, & CNA K) observed for infection control. 1. The facility failed to ensure CMA H performed hand hygiene prior to putting on gloves and after taking off gloves during incontinent care. 2. The facility failed to ensure LVN A sanitized the blood pressure cuff in between using it on different residents. 3. The facility failed to ensure CNA J performed hand hygiene after taking off gloves. 4. […]

• No harm, potential for more than minimal, patternF755Jun 29, 2023

  Based on observation, interview, and record review the facility failed to have an established system in place for accurate reconciliation for 4 (Hall 100, 200, 300 and 400) of 4 halls that had residents with orders for controlled substances. Licensed Staff were not signing Controlled Drugs Count Record when Controlled Drugs were reconciled at change of shift according to facility policy The facility failed to monitor expiration dates on the over-the-counter medication. These failures could affect residents by placing them at risk of drug diversion and receiving medication that will not provide the same result. […]