Harbor Village North Health and Rehabilitation Cen

In the surveyor’s words

From the most serious findings on record at Harbor Village North Health and Rehabilitation Cen, in the surveyor’s own words.

• Actual harm, patternF686Mar 3, 2026

  Based on observations, interviews, review of the clinical records, and facility policies, the facility failed to prevent, identify, assess, and treat pressure ulcers/injuries in accordance with resident's needs and facility policy for 2 of 3 sampled residents (Resident #3 and Resident #11). Specifically, the facility did not complete timely risk assessments or comprehensive skin assessments; failed to implement and ensure staff adherence to required offloading/turning interventions; did not measure and monitor wounds after onset; and did not follow physician orders (including heel offloading and catheter anchoring). […]

• Actual harm, isolatedF692Mar 3, 2026

  Based on observation, interviews, record and policy reviews for 1 of 4 sampled residents (Resident #3) reviewed for nutrition, the facility failed to initiate timely interventions to prevent ongoing significant weight loss. The findings include: Resident #3's diagnoses included muscle weakness, diabetes, and dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status (BIMS) of 4 indicating severe cognitive impairment and required set up help for eating and supervision with personal hygiene and toileting. […]

• No harm, potential for more than minimal, widespreadF812Jul 9, 2024

  Based on observations, review of facility policy, and interviews, the facility failed to ensure that the kitchen was kept in a clean and sanitary manner and failed to discard expired foods. The findings include: During a tour of the Dietary Department on [DATE] at 9:50 AM with the Food Service Manager the following was identified: One ceiling fan covered with a heavy coat of brownish dust-like matter blowing directly over washed silverware and mugs. The walls of the dish washing room area were covered with a coat of greyish dust-like matter. The sink area in the dish washing room was noted to have a foul odor with an accumulation of grime and dirt on the walls underneath the sink with the exposed pipes under the sink noted to have a thick black coating. […]

• No harm, potential for more than minimal, widespreadF880Jul 9, 2024

  Based on observation, facility documentation review, facility policy review, and interviews, the facility failed to follow through a resolution after identifying an issue during environmental rounds and failed to maintain a clean laundry area. The findings include: Review of the monthly facility environmental rounds from January 2024 to June 2024 identified the facility noted issues of the cleanliness in the kitchen, further review of the documentation failed to identify how the lack of cleanliness was addressed. Interview with Infection Control Nurse (ICN) LPN #5 in the presence of RN# 5 (Regional Clinical Specialist) on 7/3/24 at 10:45 AM identified that the maintenance, housekeeping, and LPN #5 were responsible for conducting the monthly environmental rounds. […]

• No harm, potential for more than minimal, patternF600Mar 3, 2026

  Based on interviews, record, and policy reviews for 2 of 3 sampled residents (Resident #15 and Resident #40) reviewed for abuse, the facility failed to ensure a resident was free from physical abuse. The findings include:1. Resident #15's diagnoses included vascular dementia with behaviors, schizophrenia and paranoid personality disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 had a Brief Interview of Mental Status of 9 indicating moderate cognitive impairment and was independent for eating, transferring, and changing position. […]