Harbor Terrace Senior Living

In the surveyor’s words

From the most serious findings on record at Harbor Terrace Senior Living, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 11, 2026

  Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 29 out of 31 residents that receive food and beverages from the kitchen, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include: During an initial kitchen tour on 3/09/26 at 9:10 AM, Certified Nurse's Aide (CNA) T revealed that the Dietary Manager was at a conference and the cook/Person in Charge was on a break. During the initial tour of the kitchen the following violations were observed: The flooring located throughout the kitchen was observed to have a build-up of debris, dust, dirt, and greasy food residue. […]

• No harm, potential for more than minimal, patternF628Mar 11, 2026

  This citation pertains to intake 2732021. Based on interview and record review, the facility failed to follow discharge policies and procedures and provide a bed hold policy for one (R35), failed to notify the family in writing for one (R37) of four residents reviewed for transfers and discharges, and failed to notify the Ombudsman of all the other discharges in the facility for several months. Findings include:Resident (R37) Review of Face Sheet revealed Resident #37 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction, vascular dementia, major depressive disorder, anxiety disorder and encounter for palliative care. R37 originally entered the facility for a 5 day respite stay. […]

• No harm, potential for more than minimal, patternF921Mar 11, 2026

  Based on observation and interview, the facility failed to maintain and repair the premises, resulting in an increased potential for contamination and a possible decrease in satisfaction of living for residents. Findings Include: On 03/10/2026 at 9:11AM observed the wall area at the dining room handsink had a crack running horizontally along the wall. The crack was about four feet long and five feet off the floor. On 03/10/2025 at 9:15AM, observed in a conference room across from the kitchen, the outside wall had a four footlong crack on the wall area close to the ceiling. During this observation, Facilities Management Support (FMS) Q, said the cracks are due to settling of the building, it is currently being monitored by an engineering team for further movement or increase in cracks. […]

• No harm, potential for more than minimal, isolatedF550Aug 26, 2026

  This citation pertains to intakes: 3044890 & 3094406Based on interview, and record review, the facility failed to ensure call lights were answered & resident needs were met in a timely manner for 3 residents (R6, R5, & R1) out of 4 residents reviewed for dignity.Findings include:Resident #6 (R6)Review of a Resident Face Sheet reflected R6 admitted to the facility on [DATE] with diagnoses that included muscle weakness, difficulty walking, anxiety, and panic disorder.Review of a Care Plan last reviewed/revised 7/17/2026 reflects Resident experiences episodes of incontinence r/t (related to) weakness, impaired mobility. The goal of the care plan was that R6 would be free of adverse effects of incontinence. […]

• No harm, potential for more than minimal, isolatedF578Aug 26, 2026

  Based on interview and record review, the facility failed to ensure follow-up on one resident (R3) out of 7 reviewed after the resident was deemed incompetent and failed to provided resident with a guardian/Medical Durable Power of Attorney. Findings include: Resident #3 (R3)Review of a Resident Face Sheet reflected R3 admitted to the facility on [DATE] and currently readmitted on [DATE] with diagnoses that included Acute on chronic diastolic (congestive) heart failure, Type 2 diabetes mellitus with diabetic chronic kidney disease stage 4 (severe), Sepsis, Dementia, Cognitive communication deficit and Multiple Sclerosis. […]