Harbour Manor Health & Living Community

In the surveyor’s words

From the most serious findings on record at Harbour Manor Health & Living Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Sep 10, 2021

  Based on interview and record review the facility failed to identify, assess and prevent residents from developing pressure ulcers. Resident B had a unstageable pressure ulcer which required surgical intervention identified on emergency room visit after an acute condition change. (Resident B) for 4 of 6 residents reviewed for pressure ulcer (Residents B, E, G, H). The immediate jeopardy began on [DATE] when Resident B developed an unstageable necrotic sacral pressure ulcer and a large fungal infection of the hips, groin and lower abdomen. The Administrator was notified of the immediate jeopardy on [DATE] at 3:22 p.m. The immediate jeopardy was removed on [DATE], but non-compliance remained at the lower scope and severity level due to ongoing monitoring. Findings include: 1. […]

• Actual harm, isolatedF600Jan 2, 2025

  Based on interview and record review, the facility failed to protect the resident's right to be free from staff-to-resident abuse perpetrated by RN 2 when the nurse held the hands of a cognitively impaired resident and administered medications while the resident was screaming for 1 of 3 residents reviewed for abuse. (Resident B) Using the reasonable person concept, this abuse could result in Resident B feeling dehumanized and anxious related to their hands being physically restrained and being forced to take oral medications. Findings include: Resident B's clinical record was reviewed on 1/2/25 at 9:13 a.m. […]

• No harm, potential for more than minimal, patternF726May 19, 2026

  Based on record review and interview, the facility failed to develop and implement a process to ensure the identity and competency of agency staff. This deficient practice had the potential to affect 122 of 122 residents in the facility. Findings include:During a confidential interview, on 5/18/26 at 11:43 a.m., it was indicated they were advised of a situation where CNA 8 was discovered to be working in more than one facility on the same date at the same time. They were able to contact both facilities and were provided with photographic evidence of CNA 8 and another employee, CNA 9, in different locations during this time frame. […]

• No harm, potential for more than minimal, patternF880Aug 16, 2022

  Based on observation, interview and record review, the facility failed to utilize proper infection prevention and control practices for residents in transmission-based precautions during a facility COVID-19 outbreak for 4 of 8 resident's reviewed for transmission-based precautions. (Residents 7, 9, 58, and 109) Findings include: During an interview at entrance conference on 8/8/22 at 10:15 a.m., the Assistant Director of Nursing (ADON) indicated the facility had 5 COVID positive residents in the facility sheltered in place without a designated COVID-19 unit. During an interview on 8/8/22 at 11:40 a.m., the ADON indicated the facilty had two additional residents positive for COVID-19. […]

• No harm, potential for more than minimal, patternF679May 21, 2021

  Based on observation, interview, and record review, the facility failed offer sufficient activities to meet residents' desires and preferences for 7 of 10 residents interviewed in a group setting (Resident 61, 90, 89, 23, 33, 7, and 36). The facility also failed to assess residents with cognitive impairments for activity needs and preferences or implement an activity program designed to meet individual resident needs for 3 of 3 dependent residents reviewed for activity programing(Residents 48, 24 and 22). Findings include: A. During a resident group interview on 5/19/21 at 1:30 p.m., with residents consisting of facility identified interviewable residents, the following activity concerns were identified: a. […]