Harbor Post Acute Center

In the surveyor’s words

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

• Actual harm, isolatedF686Oct 8, 2024

  Based on observation, interview, and record review, the facility failed to provide pressure ulcer care and treatment consistent with professional standards of practice for one resident (Resident #37) of 3 residents reviewed for care and treatment of pressure ulcers, resulting in harm and the deterioration of Resident #37's pressure ulcer. Findings include: Review of an Admission Record revealed Resident #37 (R37) admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disorder and peripheral vascular disease. Review of a Minimum Data Set (MDS) assessment for R37, with a reference date of 8/1/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R37 was cognitively intact. […]

• Actual harm, isolatedF660Jul 20, 2021

  Based on observation, interview and record review, the facility failed implement an effective discharge planning process and properly coordinate services to meet the discharge needs of 1 (Resident #14), who is dependent and discharged to home, resulting in essential supplies/medications being unavailable, lack of coordination in care for a dependent resident, mental stress, compromised physical well-being, and rehospitalization . Findings include: Review of a Face Sheet revealed Resident #14 is a [AGE] year old female originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Entry tracking Minimum Data Set (MDS) dated [DATE] revealed Resident #14 admitted to the facility. […]

• Actual harm, isolatedF684Jul 20, 2021

  This citation pertains to intake M 1197. Based on observation, interview and record review, the facility failed to assess, monitor, document and provide treatment per professional standards of care for 2 (Resident #137, Resident #139), resulting in a lack of assessments and follow up care for a resident with dysphagia and [CONDITION(S)] post hospitalization , lack of investigating care, treatments and services prior to unexpected deaths in the facility, preparing staff for emergency code procedures, and lack of necessary supplies on the crash cart. Findings include: Review of a policy titled Cardiopulmonary Resuscitation (CPR) - Adult last revised ,d+[DATE] revealed: Appropriate cardiac and respiratory function will be maintained until a definitive treatment can be given. […]

• Actual harm, isolatedF686Jul 20, 2021

  Based on observation, interview, and record review, the facility failed to assess, monitor, measure and ensure effective treatments for 1 (Resident #25) reviewed for pressure ulcers. The deficient practice resulted in Resident #25 sustaining a delay to have Stage 3 pressure ulcers assessed, measured, monitored, and treated with the potential for non-healing, infection, and further decline to occur. Findings include: Resident #25 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed Resident #25 admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF658Oct 8, 2024

  Based on interview and record review, the facility failed to provide medications upon admission in a timely manner for 1 resident (Resident #207) of 13 residents reviewed for professional standards of practice. Findings include: Resident #207 (R207) Review of an Admission Record revealed Resident #207 admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disorder and diabetes. In an interview on 10/6/2024 at 9:12 AM, R207 reported she admitted to the facility on [DATE] at approximately noon and had not been receiving all her medications since admission. Review of R207's Nursing Progress Note, dated 10/5/2024 at 1:42 PM, revealed R207 admitted to the facility on [DATE] at 1:00 PM. […]