Harborside Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Harborside Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Sep 16, 2021

  Based on a review of clinical records, facility documentation, facility policies, and resident and staff interviews, for one (1) of 44 sampled residents, the facility's staff failed to prevent and protect Resident #105 from psychological and physical abuse by Employee #5 and because of the Employee's employment history, there is a likelihood of the employee abusing other residents. Due to these failures, an immediate jeopardy situation was identified on September 8, 2021 at 1:55 PM. The facility submitted a plan of action to the survey team that was on onsite at 7:32 PM on September 8, 2021, and the plan was accepted. The survey team returned on September 16, 2021 to validate the facility's plan, and the immediate jeopardy was lifted on September 16, 2021, at 7:52 PM. […]

• Immediate jeopardy, patternF686Sep 16, 2021

  Based on observation, record reviews and staff interviews, facility staff failed to ensure that staff were reporting and documenting changes in resident skin condition as so identified. Subsequently, five (5) of five (5) residents identified by the facility as high risk for developing pressure ulcers had pressure ulcers/injuries first observed by staff at an advance stage (Stage 3, Stage 4 and Unstageable). (Residents' #87, #83, #73, #62, and #42) Due to these failures an immediate jeopardy situation was identified on September 8, 2021 at 2:01 PM. The facility submitted a plan of action to the survey team on site at 7:31 PM on September 8, 2021 and the plan was accepted. […]

• Immediate jeopardy, isolatedF678Mar 3, 2026

  Based on record reviews and staff interviews, for one (1) of 10 sampled residents, facility staff failed to accurately provide cardiopulmonary resuscitation (CPR) to Resident #5, who was found on the floor, without a pulse, not breathing, with a dislodged tracheostomy tube. During this survey, an Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.24, Quality of Life, F678, Cardiopulmonary Resuscitation on February 25, 2026 at 3:40 PM. The facility's Administrator submitted an abatement plan to the Survey Team that was accepted on February 25, 2026 at 8:19 PM. The Survey Team verified implementation of the abatement plan while onsite and the immediate jeopardy was lifted on [DATE] at 10:45 AM. […]

• Actual harm, isolatedF684Mar 3, 2026

  Based on record review and staff interviews, for one (1) of ten (10) sampled residents, facility staff failed to administer 10 doses of Resident #71's ordered anticonvulsant medication from 06/06/25 through 06/12/25. Due to these failures, Resident #71 suffered harm as evidenced by having three (3) seizures during that time frame and required hospitalization. The findings included: Review of the facility policy titled, Medication and Treatment Orders dated 12/09/25 documented in part:Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. […]

• Actual harm, isolatedF689Oct 18, 2024

  Based on record review and staff interview for one (1) of 55 sampled residents, facility staff failed to ensure that Resident #67 (who is dependent on staff for activities of daily living, bed mobility and transferring from bed to chair) received adequate supervision when staff failed to use two staff person(s) while attempting to transfer a resident from bed to chair, subsequently the resident fell from the bed to the floor and sustained a neck fracture. Actual harm was identified on 7/15/2024 for resident #67. […]