Harbor's Edge

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Feb 5, 2026

  Based on observation, staff interview, and facility documentation review, the facility staff failed to store food in accordance with professional standards for food safety in the main kitchen. The findings included:Multiple food packages and bulk food containers were opened without a label indicating an opened or used by date. A gallon container of milk was expired past the use by date and was accessible for distribution. On 2/2/2026 at 4:22 p.m. an initial tour of the main kitchen was conducted with dietary staff (other staff, OS #1 and OS #2) in the main kitchen. Prior to the kitchen tour, OS #1 was asked what the expectation of opened items (dry goods and refrigerated items) regarding labeling is. […]

• No harm, potential for more than minimal, patternF919Mar 14, 2024

  Based on staff interviews, clinical record review, and review of facility documents, the facility's staff failed to have a resident call system that consistently relayed calls directly to a staff member and/or to a centralized staff work area from each resident's bedside, toilet, and bathing area for 1 of 3 residents (Resident #1) in the survey sample. The findings included: Resident #1 was originally admitted to the facility from a local hospital on [DATE] for rehabilitation services after coronary artery bypass graft surgery. The admission diagnoses included coronary artery disease, hypotension, hyperlipidemia, chronic kidney disease, dysphagia, history of breast cancer, anxiety, depression, and obesity. […]

• No harm, potential for more than minimal, isolatedF607Aug 11, 2022

  Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy regarding the screening of employees for 9 employees no reference checks were obtained and for 3 employees no sworn disclosure statements were obtained in a sample of 19 employee records reviewed. The findings included: On 8/11/22, a review of 19 employee files was conducted and revealed the following: 1. The facility staff failed to obtain employee References for nine employees. The employee record review revealed that 9 current employees did not have reference checks. […]

• No harm, potential for more than minimal, isolatedF641Aug 11, 2022

  Based on information gleamed during a closed record review and staff interviews, the facility staff failed to complete an accurate discharge Minimum Data Set (MDS) assessment for 1 of 22 residents (Resident #27), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 5/24/22 and discharged from the facility to the community 7/2/22. The discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. […]

• No harm, potential for more than minimal, isolatedF849Aug 11, 2022

  Based on staff interview and clinical record review, the facility's staff failed to ensure a resident who had elected hospice services, their written care plan included both the most recent hospice care plan as well as the facility's care plan for 1 of 22 residents (Resident #3), in the survey sample. The findings included: Resident #3 was originally admitted to the facility 1/3/22 and had never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/25/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. […]