Mercy Harvard Hospital Care Center

In the surveyor’s words

From the most serious findings on record at Mercy Harvard Hospital Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Apr 9, 2024

  Based on observation, interview and record review the facility failed to ensure the water system was flushed to prevent Legionnaire disease in the water. This applies to all 16 resident residing in the facility. The findings include: The facility's Long-Term Care Facility Application For Medicare and Medicaid (CMS-671) dated 4/8/24 shows a facility census of 16. On 04/09/24 at 10:15 AM, V5 Facility Manager said the facility had a recent low level positive for bacteria on the Legionella testing. V5 said the positive water sample came from an unoccupied resident room and was found during quarterly testing of dead leg areas (water not used frequently). V5 said the water supply comes from the city and is chlorinated. […]

• No harm, potential for more than minimal, widespreadF812Apr 6, 2021

  Based on observation, interview, and record review, the facility failed to ensure the quat sanitation was maintained at the appropriative level for disinfecting in the kitchen. This applies to all residents residing in the facility. The findings include: On April 5, 2021 at 8:48 AM, a tour of the kitchen was performed with V5 (Dietary Manager). V5 tested the red quat sanitation bucket with the test strip. V5 said the test strip reading shows the sanitation bucket was at 100 ppm (parts per million). V5 said it should be at 200 ppm, and the sanitation buckets should be changed every two hours. The Resident Census and Conditions of Residents form, dated April 5, 2021, shows 18 residents residing in the facility. […]

• No harm, potential for more than minimal, widespreadF886Apr 6, 2021

  Based on observation, interview, and record review, the facility failed to perform COIVD-19 testing weekly for a staff member. This applies to all residents residing in the facility. The findings include: The Resident Census and Conditions of Residents form, dated April 5, 2021, shows 18 residents residing in the facility. The laboratory COVID-19 test for V6 (CNA) was performed on 2/22/21, 3/1/21 and 3/15/21 (14 days later). The facility's schedule for the week of 3/7/21 to 3/13/21 shows V6 worked on 3/9/21, 3/10/21, and 3/12/21. On April 5, 2021 at 2:23 PM, V2 (Assistant Administrator) said V6 missed her test date on 3/8/21. V2 said V6 continued to work until she was testing the following week on 3/15/21. V2 said staff should be taken of the schedule until they are tested . […]

• No harm, potential for more than minimal, isolatedF689Feb 18, 2026

  Based on observation, interview, and record review, the facility failed to transfer a resident (R1) with a gait belt. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 14. The findings include:R1's electronic face sheet printed on 2/18/26 showed R1 has diagnoses including but not limited to chronic hypoxic respiratory failure, chronic bronchitis, atrial fibrillation, hypotension, pleural effusion, ostomy, left hemicolectomy, and Alzheimer's dementia without behaviors R1's fall risk assessment dated [DATE] showed R1 is a high fall risk. R1's care plan dated 6/7/25 showed, (R1) is at risk for falling due to unsteady gait, impaired balance, poor activity tolerance with continuous oxygen, previous CVA (cerebrovascular accident), and weakness. […]

• No harm, potential for more than minimal, isolatedF755Feb 18, 2026

  Based on observation, interview, and record review the facility failed to check expiration dates of insulin prior to administering expired insulin to a resident (R3). This applies to 1 of 1 resident reviewed for medications in the sample of 14. The findings include:R3's Physician Orders showed an order for fast-acting ranging from 0-12 units to be given at mealtimes. On [DATE] at 1:07 PM, V4 Registered Nurse (RN) began preparing R3's insulin pen. R3's insulin pen showed a handwritten date of [DATE] denoting the date it was placed into service. Below was a handwritten expiration date, Exp 1/29. V4 prepared this fast acting insulin pen and injected 4 units of insulin into R3's right lower abdomen. V4 stated the date of [DATE] was the date the pen was opened and first used. […]