Harvard Gardens Rehabilitation & Care Center

In the surveyor’s words

From the most serious findings on record at Harvard Gardens Rehabilitation & Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Dec 1, 2022

  Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID-19 positivity log, review of facility infection control policies, interviews with staff, observations, interview with the local health department (LHD) and medical record review, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19. This resulted in Immediate Jeopardy on 11/17/22 when Resident #47 tested positive for COVID-19 exposing Resident #33. The facility cohorted exposed COVID-19 negative Resident #33 with COVID-19 positive Resident #47. […]

• Immediate jeopardy, isolatedF689Nov 1, 2022

  Based on observations, interviews, record review, facility self-reported incident (SRI), police report review, facility policy review, and review of weather information from www.wunderground.com, the facility failed to provide accurate and timely assessment, care planning and supervision to prevent the elopement of one resident (Resident #21) who had diagnoses including anxiety and [CONDITION(S)]. This resulted in Actual Harm that was Immediate Jeopardy when Resident #21 was dropped off at a medical appointment in the community and subsequently left the appointment without facility staff knowledge on 10/11/22. […]

• Actual harm, isolatedF694Apr 15, 2026

  Based on medical record review, review of facility policy, review of informational articles from American Cancer Society, and interview the facility failed to develop and implement a system for identifying, monitoring, and caring for Resident #3's implanted venous access device (a port placed under the skin for use to administer intravenous treatments to mitigate risk for infection. This affected one resident (#3) of three residents reviewed for vascular access devices. The facility census was 102.Actual Harm occurred on 03/04/26 when Resident #3 was identified by a non-facility oncology nurse at an outside appointment to have a dressing to an implanted venous access device that was heavily soiled. […]

• Actual harm, isolatedF684Apr 10, 2025

  Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #10 received timely medical intervention for an acute change in condition. Actual Harm occurred on 03/18/25 at 1:49 A.M. when Resident #10 complained of numbness of the right side of the body and requested to go to the hospital. However, the resident was not transferred to the hosptial until 03/18/25 at 4:08 A.M. Hospital documentation revealed the resident was admitted for a cerebrovascular accident due to intracerebral hemorrhage, ischemic stroke. The resident reported he had complaints of right-sided weakness approximately four days ago which he described as a heaviness to his upper and lower extremities. […]

• Actual harm, isolatedF686Sep 28, 2023

  Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent an in-house acquired pressure ulcer for Resident #14. Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, the area declined to a Stage IV pressure ulcer with odor noted with recommendation for hospitalization and possible amputation. This affected one resident (#14) of three residents reviewed for pressure ulcers. […]