Harbourwood Post-Acute and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Harbourwood Post-Acute and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, patternF600Jul 28, 2025

  Based on record review and interviews, the facility failed to follow professional standards of care and protect the residents' right to be free from neglect for two residents (#3, and #4) out of four residents sampled related to 1) failure to follow up physician orders for laboratory and radiology testing, and failure to report abnormal laboratory test results. Findings included:Review of Resident #3's admission record revealed an initial admission date of 8/20/24 and a readmission date of 7/20/25 from a hospital stay, and a discharge date of 3/30/25, with diagnoses to include metabolic encephalopathy-7/20/25, acute renal failure with hypoxa-7/20/25, atrial fibrillation,- 7/20/25 and chronic kidney disease (stage 2) -8/20/24. […]

• Actual harm, patternF726Jul 28, 2025

  Based on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for three residents (#1, #3, and #4) out of four residents sampled related to: 1) failure to recognize a change in condition and provide care resulting in a hospitalization 2) failure to follow physician orders for laboratory testing; 3) failure to report abnormal laboratory results.Findings Included: A review of Resident #3’s admission record revealed an initial admission date of 8/20/24 and a readmission date of 7/20/25 from a hospital stay, and a discharge date of 3/30/25, with diagnoses to include metabolic encephalopathy-7/20/25, acute renal failure with hypoxa-7/20/25, atrial fibrillation,- 7/20/25 and chronic kidney… […]

• Actual harm, isolatedF600Apr 14, 2025

  Based on observations, review of medical records and facility policies, and interviews with residents and physicians, the facility failed to protect the resident's right to be free from physical, verbal and psychological abuse and failed to identify, correct and intervene in situations in which abuse and neglect was more likely to occur for one resident (#1) of two residents sampled. Findings included: During an interview on 04/13/25 at 10:51 a.m. Resident #1 stated he was forced to receive care by an [African American] CNA (Certified Nursing Assistant) who is a profanity, too rough and always has to have his way. Resident #1 said, I sometimes refuse care, but the [African American] CNA forced me to accept his care. […]

• No harm, potential for more than minimal, widespreadF812Apr 15, 2021

  Based on observations, staff interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by 1. failed to ensure one of one low temperature dish machine was operating effectively and per the machine specifications during one of four days observed. 2. failed to ensure one of three facility refrigerators, used by staff and residents, were clean and maintained with packaged outside source food items properly labeled and dated. Findings included: 1. On 4/12/2021 at 9:15 a.m., the initial kitchen tour was conducted with the Certified Dietary Manager (CDM). The CDM revealed the dish cleaning machine was a low temp machine with chemical sanitizer. […]

• No harm, potential for more than minimal, patternF759May 18, 2026

  Based on interview, record review and clinical professional standards, the facility failed to ensure medications were administered as prescribed, with physician orders for four residents (#1, #2, #3, and #10) out of six sampled.Findings Included: A review of Resident #1's admission record showed an admission date of 4/22/2026, with diagnoses including type 2 Diabetes Mellitus, protein calorie malnutrition, and high blood pressure. A review of Resident #1's physician order summary report showed orders dated 4/22/26 for the following: oxycodone 5 mg (milligram) by mouth every 6 hours as needed for pain, pain evaluation every shift to monitor the resident's pain level, and pain management consult with treatment as needed. A review of Resident #1's nurse's note dated 4/23/26 at 3:57 p.m. […]