Harbor Post Acute Care Center

In the surveyor’s words

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

• Actual harm, isolatedF684Jan 12, 2021

  Based on interview and record review, the facility failed to follow a physician's discharge summary order for a prescribed blood thinner medication and a plan of care which indicated the medication should be given as prescribed for one of three sampled residents (Resident 1). Resident 1, who had a history of [REDACTED].'s discharge order for 10 days. This deficient practice resulted in Resident 1 abruptly not receiving [MEDICATION NAME] and having a change of condition (COC) of an altered mental status (AMS), which required a readmission to the GACH 10 days after admission to the SNF. […]

• No harm, potential for more than minimal, widespreadF812Aug 15, 2025

  Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1. 1 box of Boost (nutritional drink)supplement with 19 brick pack remaining were stored in the dry storage area with no date and label.2. 1 box of chocolate fat free ice cream with 26 cups remaining were stored in freezer #1 with no date and label.3. 1 box of [NAME] house honey wheat roll dough were stored in freezer #1 with no date and label.4. 1 box of liquid whole eggs pasteurized with 11 brick pack remaining were stored in refrigerator #1 with no date and label. […]

• No harm, potential for more than minimal, widespreadF880Aug 15, 2025

  Based on interview, and record review, the facility failed to:Ensure a comprehensive water management program was in place.Ensure the Infection Prevention Control Program (IPCP) including standards, polices, and procedures were current, based on national standards, and reviewed at least annually.Ensure gloves were worn while disinfecting the bedside table and prepping wound care supplies for one of one sampled resident (Resident 5).These deficient practices had the potential for staff to follow outdated policies, placing residents and staff at risk for cross contamination and transmission of diseases within the facility.Findings: 1. […]

• No harm, potential for more than minimal, widespreadF812Aug 9, 2024

  Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 106 out 108 total residents in the facility by not: A. Ensuring Foods were dated, labeled, and discarded before the used by date (expiration dates). B. Ensuring Dietary Aid (DA) 2 performed hand hygiene (washing hands) and changed gloves between tasks during tray line (Resident's trays are assembled and check for accuracy before food is delivered to them). C. […]

• No harm, potential for more than minimal, widespreadF925Oct 4, 2022

  Based on observation, interview and record review the facility failed to maintain an effective pest control program to prevent the presence of cockroaches (small insects that cause the spread of bacterial infection) in the facility. The deficient practice placed the 108 residents at risk of vector-borne diseases (illnesses that results from infections transmitted to humans by insects, such as cockroaches.). On October 4, 2022, at 4:00 p.m. , respectively, the Registered Environmental Health Specialist (REHS is a health inspector who inspects various facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections.) and the surveyor observed live cockroaches in the facility's kitchen.and failed to prevent cockroaches from living and harboring… […]