Harborview Health Systems Jesup

In the surveyor’s words

From the most serious findings on record at Harborview Health Systems Jesup, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 7, 2026

  Based on observations, staff interviews, record review, and review of the facility policy titled Date Marking for Food Safety, the facility failed to store and prepare food under sanitary conditions. Specifically, food items located in the dry storage were expired and kitchen equipment was not clean. This deficient practice increased the risk of foodborne illness for the 85 residents receiving an oral diet from the kitchen. Findings include:Review of the facility's policy titled Date Marking for Food Safety, last revised 06/01/2024, documented under Policy Explanation and Compliance Guidelines for Staffing, The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The opening or preparation counts as day 1. […]

• No harm, potential for more than minimal, widespreadF908May 7, 2026

  Based on observation, interview, and document review, the facility failed to assure dietary department equipment was in safe working condition. Specifically, the steam table located in the kitchen was in disrepair. The failure to assure that the steam table worked correctly had the potential to impact 85 residents that received oral diets from the kitchen steam table. Findings include:Review of the facility's policy titled Record of Food Temperatures, last revised 06/01/2024, documented under Policy Explanation and Compliance Guidelines, number 2. Hot food will be held at 135 degrees Fahrenheit or greater; number 8. If the food temperature falls into an unsafe range, immediately follow procedures for reheating previous cooked food; number 9. […]

• No harm, potential for more than minimal, widespreadF880May 27, 2021

  Based on observations, staff interviews, and facility policy review, the facility failed to follow transmission-based precautions related to wearing appropriate Personal Protective Equipment (PPE) for infection control measures for residents on isolation precaution in rooms 103, 105, 117) and failed to doff PPE when exiting a resident's room. The facility failed to remind residents to wear a mask when out of their rooms. In addition, the facility failed to ensure the indwelling catheter bag was not touching the floor for one of two sampled residents (R33). Findings include: 1. Observation on 05/24/21 at 9:02 AM, of the 100-hall during the initial tour of the facility revealed three resident rooms (Room103, 105, and117) had a clear plastic covering over the doors leading into the rooms. […]

• No harm, potential for more than minimal, patternF582May 27, 2021

  Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) that was completed accurately for two of three residents (R61, R73) when their Medicare Part A stay was ending. The facility did not include information on how to appeal the decision made by the facility. Findings include: 1. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R61 was admitted on [DATE] to the facility. She received Part A Medicare services until 05/21/2021. Further review revealed she was issued a SNF ABN on 05/18/2021 and chose to remain in the facility. […]

• No harm, potential for more than minimal, isolatedF759Apr 27, 2023

  Based on observations, interviews, review of facility policy, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%). There were 2 errors made in 27 opportunities, resulting in a medication error rate of 7.40%. These errors affected 1 (Resident #79) out of 4 residents observed during medication pass. Findings included: A review of the facility's policy titled, Medication Administration, with an implementation date of 1/1/2023, indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. […]