Harbor Villa Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF689Aug 23, 2022

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for 15 of 15 residents (Residents 2, 10, 11, 24, 37, 39, 43, 53, 56, 63, 71, 76, 79, 92, and 394) who smoked in the facility. * The facility failed to ensure the safe smoking practices were followed for 15 residents who smoked in the facility as evidenced by: - The residents were not accurately and thoroughly assessed to determine if they required supervision or any adaptive safety equipment while smoking, nor if they could safely store their own cigarettes or lighters. […]

• Actual harm, isolatedF684Jul 6, 2023

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) maintained their highest practicable physical, mental, and psychosocial well-being as evidenced by: * The facility disregarded two separate physician's orders to have Resident 1 assessed by a dermatologist for the progression of a skin lesion/mass on the resident's left forearm, despite Resident 1's history of skin cancer. The lesion measured 0 cm in depth (height) on 3/3/23, increased to 0.5 cm on 4/5/23, and further grew to 3.7 cm in depth on 5/19/23. […]

• No harm, potential for more than minimal, patternF686Apr 10, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for two of three final sampled residents (Residents 10 and104) reviewed for pressure injuries. * The facility failed to offload Resident 10's heels, as ordered by the physician and failed to provide a pressure relieving mattress with a pump as ordered by the physician. * The facility failed to offload Resident 104's heels as ordered by the physician. […]

• No harm, potential for more than minimal, patternF760Apr 10, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one two of four residents (Residents 6 and 44) observe for the medication administration were free from the significant medication errors. * LVN 1 administered the furosemide (medication to treat fluid retention) medication outside the physician's ordered parameter for Resident 6. * LVN 3 administered the heparin (blood thinner) medication without a physician's order for Resident 44. These failures posed the risk of adverse complication to the residents.Findings: Review of the facility's P&P titled Administering Medications (undated) showed the medications are administered in accordance with prescriber orders, including any required time frame. […]

• No harm, potential for more than minimal, patternF804Apr 10, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure to prepare food by methods that conserve nutritive value and at safe and appetizing temperature for 11 residents that consumed pureed food and 45 residents on Regular Diet Texture. * The prepared pureed vegetables were left in the oven for more than one hour before the lunch food tray line. * The ham temperature was at 98 degrees Fahrenheit. These failures had the potential for the residents not to eat the food served and could affect the residents nutritional status. […]