Harlan Health and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF656Mar 21, 2025

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and/or implement a comprehensive person-centered care plan related to dental needs to ensure that medical, nursing, mental and psychosocial needs related to weight loss were met for one (Resident (R) 99) of seven residents reviewed for nutrition out of a sample of 49 residents. R99 sustained pain and a severe weight loss of 20% in the six months between 09/17/2024 and 03/10/2025. The findings include: Review of the facility's policy Care Plan Policy and Protocol, revision 09/2024, revealed the care plan would be updated as indicated with changes in condition, physician orders, fall interventions, etc. […]

• Actual harm, isolatedF692Mar 21, 2025

  Based on observation, interview, record review, and review of the facility's policy, the facility failed to maintain acceptable parameters of nutritional status such as body weight for one (Resident (R) 99) of seven residents reviewed for nutrition, out of a total sample of 49 residents. R99, who had significant dental breakdown, experienced pain and sustained a severe/significant unplanned weight loss that continued for at least six months after the facility was notified that the resident needed dental care. […]

• Actual harm, isolatedF790Mar 21, 2025

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide/obtain needed dental care for one of 49 sampled residents (Resident (R) 99) who was reviewed for dental services. The facility failed to obtain needed dental services over a nine-month period for the resident who had multiple broken teeth which needed extraction. During this time, the resident sustained pain, as well as, a severe weight loss over a six and nine-month period. The findings include: Review of the facility's policy titled, Protocol for Oral Status Assessment, revision date 08/2017, revealed An assessment of the oral cavity of each resident will be completed annually by a nurse. […]

• No harm, potential for more than minimal, widespreadF922Mar 21, 2025

  Based on observation, interview, and record review, the facility failed to ensure it had safe drinking water available when there was a loss of normal water supply for all residents. This had the ability to affect all 132 residents. The findings include: In an interview with the Administrator, on [DATE] at 11:10 AM, she stated the facility did not have a policy to address the availability of water when there was a loss of normal water supply. Further, she stated it was her expectation that the facility would have drinkable water available each day for a period of three days, for the residents consumption. Review of the facility's Water Utility Agreement, dated [DATE], revealed the city's Municipal Water Works assisted the facility with emergency water access. […]

• No harm, potential for more than minimal, patternF761Apr 15, 2021

  Based on observation, interview, and facility policy review, it was determined the facility failed to label and store biologicals with currently accepted professional principles for one (1) of five (5) medication carts observed. Four (4) multi-dose vials of Insulin which were not dated when opened were observed on one (1) medication cart on the west wing. In addition, one of the vials of insulin did not have a pharmacy label which included the resident's name, medication name, dose, route, etc. The findings include: Review of the facility's policy titled, Protocol for Multi-Dose Vials, undated, revealed multi dose vials should be initialed and dated when opened and stored per manufacturers recommendations. […]