Harbour Health Center

In the surveyor’s words

From the most serious findings on record at Harbour Health Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 8, 2025

  Based on record review, review of facility policy and procedures, resident and staff interviews, the facility failed to protect the resident's right to be free from physical abuse for 1 (Resident #899) of 3 residents reviewed for abuse. The findings included:A review of the facility policy Identifying Types of Abuse documented, Abuse of any kind against residents is strictly prohibited. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. It is understood by the leadership in this facility that preventing abuse requires staff education, training, and support, and a facility wide culture of compassion and caring. […]

• No harm, potential for more than minimal, patternF732Feb 8, 2024

  Based on observation and interview, the facility failed to ensure they posted and updated the nurse staffing information with the facility name and an updated census per shift. The facility further failed to maintain the nursing staffing information for 18 months. The findings included: On 2/5/24 at 9:10 a.m. via observation, the nurse staffing information form dated 2/5/24 located in the main lobby did not have the facility's name and the current census. On 2/5/24 at 4:00 p.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/05/24. On 2/06/24 at 10:10 a.m. […]

• No harm, potential for more than minimal, patternF600May 9, 2022

  Based on observation, review of facility's policy and procedure, record review, and staff interview, the facility failed to establish a complete and accurate system to prevent misappropriation of residents' narcotic medications. The findings included: The facility's policy titled Abuse Prevention Program revised December 2016 read, Our residents have the right to be free from . misappropriation of resident property and exploitation . The facility's policy for, Investigating Incidents of Theft and/or Misappropriation of Resident Property read, Residents have the right to be free from theft and/or misappropriation of personal property. […]

• No harm, potential for more than minimal, patternF755May 9, 2022

  Based on observation, review of facility's policy, record review and staff interview, the facility failed to establish a reliable system to dispose of unused narcotics, creating a potential for drug diversion by staff. The findings included: Record Review of the facility policy Controlled Substances, Revised April 2019 read, . Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. On 5/9/22 at 10:49 a.m., the Human Resources Director said the Assistant Director of Nursing (ADON) was recently terminated for stealing residents' narcotics for personal use. […]

• No harm, potential for more than minimal, isolatedF684Mar 26, 2026

  Based on observation, record review, resident and staff interviews, the facility failed to ensure 1 (Resident #7) of 3 residents reviewed, received care and services in accordance with the care plan and physician's orders to maintain skin integrity.The findings included:Review of the clinical record for Resident #7 revealed a readmission date of 6/8/23. Diagnoses included dementia, heart failure and type 2 diabetes.The Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/15/26 revealed Resident #7 scored 13 on the Brief Interview for Mental Status, indicating intact cognition.The care plan initiated on 6/12/23 and revised on 12/08/25 revealed Resident #7 had a potential for impaired skin integrity related to impaired mobility, fragile skin, diabetes, neuropathy (damage… […]