Harvard Creek Post Acute

In the surveyor’s words

From the most serious findings on record at Harvard Creek Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Feb 13, 2026

  Based on interview and record review, the facility failed to develop and implement individualized and resident-centered care plans (CP) for two of two sampled residents (Residents 26 and 53).These deficient practices had the potential for Residents 26 and 53 to not receive appropriate care, treatment, and/or services related to their specific needs.Findings: a. During a review of Resident 26's admission Record (AR), the AR indicated Resident 26 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract) and bronchitis (the air tubes in the lungs got swollen and made breathing hard). […]

• No harm, potential for more than minimal, patternF921Feb 13, 2026

  Based on observation and interview, the facility failed to ensure the kitchen handwashing sink was draining.This failure had the potential to result in overflow of wastewater and lead to contamination.Findings:During an observation on 2/10/2026 at 8:59 AM in the kitchen, the handwashing sink was half-full of soapy, dirty water. During an interview on 2/10/2026 at 9:00 AM with Dietary Supervisor (DS), DS stated the sink drains slow, it could be clogged. DS stated the sink should be draining smoothly otherwise it might overflow and contaminate surrounding kitchen area. […]

• No harm, potential for more than minimal, patternF558Dec 20, 2024

  Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for three of three sampled residents (Residents 13, 17 and 35). These deficient practices had the potential for the residents not to receive necessary care or receive delayed services to meet the residents' needs that could result in a fall or injury. Findings: a. During a review of Resident 17's Admission Record (AR), the AR indicated, Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints caused by gradual loss of cartilage), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and chronic obstructive pulmonary disease (COPD,… […]

• No harm, potential for more than minimal, patternF700Dec 20, 2024

  Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of side rails/bed rails (adjustable metal or rigid plastic bars attached to the bed) for three of three sampled residents (Residents 21, 33 and 48) by failing to: a. (1). Ensure appropriate alternative interventions were attempted before the installation of side rails for Resident 21. (2). Assess Resident 21 for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) and obtained an informed consent to review the risks and benefits prior to installing bed rails. b. […]

• No harm, potential for more than minimal, patternF812Dec 20, 2024

  Based on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure food items were dated when it was first opened in one of two facility refrigerators. This deficient practice had the potential risk for food borne illnesses (infections caused by ingesting contaminated food or beverages) to the residents. Findings: During an observation and initial tour of the kitchen on 12/17/2024 at 9:24 am, together with the Lead [NAME] (LC), one unlabeled bag of tortilla and 2 pound (lbs.- unit of measurement) open bag of corn tortilla did not have a label or date when it was first opened, inside one facility refrigerator. The LC stated the bags of tortillas were not labeled nor dated when it was first opened. […]