Premier Healthcare at Harrington House

In the surveyor’s words

From the most serious findings on record at Premier Healthcare at Harrington House, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 3, 2025

  Based on observation, interview, and document review, the facility failed for one Resident (#77), out of a sample of 18 residents, to ensure the Resident received consistent care and treatment to prevent the further deterioration of a deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin often appearing as a deep bruise) to the right heel that went from dime sized and intact on 3/29/25 to quarter sized and open with drainage on 4/3/25. Findings include: Review of the facility's policy titled Pressure Injury Prevention and Management, dated as reviewed 10/2024, indicated but was not limited to the following: - the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and… […]

• No harm, potential for more than minimal, widespreadF844Apr 3, 2025

  Based on interview and review of the Health Care Facility Reporting (HCFS-State agency reporting system), the facility failed to provide written notice to the State Agency when a change in the facility's Administrator and Director of Nursing (DON) occurred. Findings include: During the entrance conference interview on 3/31/25 at 8:59 A.M., the Administrator said she was the facility's new Administrator, effective 3/10/25, and the facility had a new Director of Nursing (DON), effective 3/15/25. […]

• No harm, potential for more than minimal, widespreadF880Apr 3, 2025

  Based on records reviewed and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to: 1. Perform surveillance activities to monitor and investigate causes of infections and the manner of spread throughout the facility; 2. Have a facility specific written water management plan to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system; 3. […]

• No harm, potential for more than minimal, widespreadF881Apr 3, 2025

  Based on record review and interview, the facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. Findings include: Review of the facility's Antibiotic Stewardship Program policy, undated, indicated but was not limited to the following: - It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. […]

• No harm, potential for more than minimal, patternF656Apr 3, 2025

  Based on observation, interview and record review the facility failed to develop, implement and individualize comprehensive care plans for four Residents (#10, #29, #12, and #73), out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #10, a comprehensive care plan was developed to address the use of Quetiapine Fumarate (Seroquel-antipsychotic medication) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment; 2. For Resident #29, a comprehensive care plan was developed to address the use of Risperdal (antipsychotic medication) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment; 3. […]