Harborside Health & Rehabilitation

Penalty

Inspection fine: $117,516

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to accurately provide cardiopulmonary resuscitation (CPR) to a resident who was a full code and dependent on a tracheostomy, resulting in a deficiency cited under 42 CFR 483.24, F678, Cardiopulmonary Resuscitation. The facility’s CPR policy required adherence to American Heart Association (AHA) guidelines, including immediate initiation of CPR when an individual is found unresponsive with absent or abnormal breathing, continuous chest compressions at a rate of 100–120 per minute, provision of rescue breaths, and not leaving the person alone except when absolutely necessary to call for help. The AHA guidance referenced in the report also specified that CPR for a person with a tracheostomy involves 30 chest compressions followed by 2 breaths delivered via the tracheostomy tube using an Ambu bag or mouth-to-trach, and that if the tracheostomy tube is dislodged or blocked, it should be replaced or the stoma covered to provide rescue breathing. The resident involved had multiple significant medical diagnoses, including acute respiratory failure with hypoxia, epilepsy, dysphagia following cerebral infarction, diabetes mellitus, and schizophrenia. The resident had a physician’s order for full code status and care plans identifying risks for respiratory and cardiac complications, with interventions such as administering medications and treatments as ordered, monitoring for signs and symptoms of respiratory and cardiac complications, and providing tracheostomy care and respiratory therapy services. An admission MDS indicated the resident was cognitively intact with a BIMS score of 13, had functional limitations in upper extremities but no lower extremity impairment, used a walker, required partial/moderate assistance for some transfers, and received oxygen, tracheostomy care, and respiratory therapy. During night shift rounds at approximately 3:00 AM, the nurse supervisor (Employee #6) found the resident lying supine on the floor near the doorway, unresponsive, without a pulse or respirations, with the inner cannula of the tracheostomy tube dislodged. The nurse supervisor reported performing a brief assessment, confirming the absence of pulse and respirations, and initiating chest compressions for about three minutes but did not provide any rescue ventilation via the tracheostomy site using an Ambu bag or other method. Contrary to AHA guidance and facility policy that require not leaving a collapsed person who needs CPR, the nurse supervisor stopped CPR and left the resident alone to go to the nurses’ station to get help, stating she did not use the call light or shout for help because it was 3:00 AM and she did not want to wake other residents. She also initially called a “Rapid Response” rather than a “Code Blue,” despite the resident being pulseless and not breathing. When the respiratory therapist (Employee #9) arrived in response to the calls, the resident was on the floor on his back with several people present who were not administering CPR. The respiratory therapist assessed that the resident was not breathing, retrieved the Ambu bag from the bedside, connected it to oxygen, and began chest compressions with one hand while providing rescue breaths with the other. The therapist observed that the tracheostomy tube was dislodged and on the floor and was able to reinsert it without incident before continuing CPR with assistance from another respiratory therapist. The DON later confirmed that staff are trained that a Code Blue is automatic when someone collapses and has no pulse or is not breathing. The evidence showed that staff actions deviated from AHA-based facility policy by leaving the resident during CPR, failing to provide appropriate rescue breathing via the tracheostomy, and initially calling a Rapid Response instead of a Code Blue for a pulseless, non-breathing resident, leading to the cited deficiency. The resident was subsequently pronounced deceased at 3:51 AM after EMS arrived and continued advanced cardiovascular life support. The surveyors determined that these failures constituted an Immediate Jeopardy situation related to the provision of CPR under F678.

Removal Plan

• Remove Employee #6 from resident care pending investigation and re-education.
• Re-educate all licensed nurses on AHA CPR/BLS requirements.
• Re-educate all licensed nurses on performing continuous chest compressions without leaving the resident.
• Re-educate all licensed nurses on proper ventilation for residents with tracheostomies (use of Ambu bag via trach; management of dislodged trach).
• Re-educate all licensed nurses on clear differentiation between Code Blue and Rapid Response.
• Include in education: 30 compressions at 100-120/minute.
• Include in education: rescue breathing via tracheostomy.
• Include in education: procedure if tracheostomy becomes dislodged.
• Require all licensed staff to maintain current AHA BLS certification.
• Implement mock Code Blue drills.
• Post Code Blue vs Rapid Response criteria at nurses' stations.
• Conduct an immediate 100% chart audit of all residents with physician orders for fall/safety assessments to verify appropriateness and implementation.
• Verify all physician orders for fall/safety assessments on MAR/TAR are being implemented.
• Address any missing documentation for ordered assessments.
• Re-educate nurses on required documentation of ordered assessments.
• Conduct a 100% audit of care plans for residents at risk for falls and update them to include more than one individualized, multi-factor fall prevention intervention.
• Provide education on care plans, Code Blue vs Rapid Response, CPR response and compliance, and physician orders/implementation of fall/safety assessments.
• Provide education by the educator/designee for all licensed staff starting night shift.
• Provide education for all other licensed staff prior to or at the start of their shift.
• Continue training until all licensed staff have been educated.

Penalty

Inspection fine: $117,516

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to provide ordered anticonvulsant medication to a resident with a convulsion disorder, resulting in missed doses over several days. The resident had a history of convulsions related to head injury, hypertension, and spastic hemiplegia, with an active diagnosis of epilepsy and an order for Lacosamide 200 mg orally twice daily for seizure precautions. The resident’s care plan required seizure medication to be given as ordered and monitored for effectiveness and side effects. The controlled drug record showed the last available dose of Lacosamide was administered on 06/06/25 at 10 PM, with a count of zero tablets remaining, and the facility’s policy required refills to be ordered at least three days before the last dose. From 06/07/25 through 06/12/25, the Medication Administration Record (MAR) documented that multiple scheduled doses of Lacosamide were not administered, with entries of “5=Hold/See Progress Notes” and “9=Other/See Progress Notes” at several administration times. Despite this, an LPN documented check marks and initials on the MAR indicating that Lacosamide was administered on three evenings, even though there was no evidence that the medication had been removed from the Omnicell or delivered from the pharmacy, and the controlled drug disposition form showed no doses available after 06/06/25. Pharmacy records confirmed that no additional doses had been ordered or delivered after that date, and a prescription written on 06/06/25 was not faxed to the pharmacy until 06/12/25. During the period when doses were missed, the resident experienced changes in condition and seizure activity. On 06/09/25, security staff reported that the resident was not responding as usual, and the resident was assessed with the MD made aware but no new orders given. On 06/11/25, the resident had a seizure after smoking, with tongue biting and bleeding, and was transported to the hospital. The resident returned later that day, and on 06/12/25, nursing documentation noted that the resident did not have Lacosamide 200 mg available. That same morning, the resident had another tonic-clonic seizure, followed by another seizure and an episode of coffee-brown emesis, leading to a rapid response and transfer to the hospital. The resident was later discharged from the hospital after treatment for seizures and bacteremia. The facility’s review concluded that the resident missed a total of 10 doses of Lacosamide, that staff did not timely fax the prescription, did not administer available doses from the Omnicell, and did not notify the physician that multiple doses had been missed.

Penalty

Inspection fine: $117,516

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to meet the State requirement of providing a minimum daily average of 4.1 hours of direct nursing care per resident per day on 02/22/26, when the census was 117 residents and the facility’s total direct care staffing level was 4.0 hours. On that same date, a facility reported incident documented that at approximately 3:00 AM, Resident #5 was found in the doorway of his room with his tracheostomy dislodged. An Immediate Jeopardy was identified at 42 CFR 483.24, F678, related to cardiopulmonary resuscitation on 02/25/26 at 3:40 PM. During a face-to-face interview on 03/03/26, the staffing coordinator calculated the total direct care staff, acknowledged that the 4.1-hour requirement was not met on 02/22/26, and stated that staffing had generally been good but that on some days replacements could not be obtained for staff who called out. The deficiency centers on the facility’s failure to comply with State minimum direct care staffing requirements on 02/22/26, in the context of an incident where a resident with a tracheostomy was found with the trach dislodged during the early morning hours, and the subsequent identification of Immediate Jeopardy related to cardiopulmonary resuscitation requirements.

Penalty

Inspection fine: $117,516

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to timely report an incident of suspected abuse, neglect, or mistreatment, as required by the facility’s Abuse Investigation and Reporting policy, which mandates that alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but not later than two hours. The incident involved a resident with multiple diagnoses, including acute respiratory failure with hypoxia, epilepsy, dysphagia following cerebral infarction, diabetes mellitus, and schizophrenia, who was admitted on a prior date. At approximately 3:00 AM, during a supervisor’s round, the resident was found on the floor in the doorway of the room, lying in a supine position, unresponsive, with the tracheostomy dislodged. A rapid response was called, CPR was initiated by the code team, and EMS (911) arrived and continued ACLS protocols. Despite the seriousness of the event and the resident being pronounced deceased at 3:51 AM after several rounds of CPR, the facility did not report the incident to the State Agency until approximately 7:26 PM the same day, about 16.5 hours after the incident occurred. The Facility Reported Incident documented that the resident was found in the doorway with the trach dislodged and that an investigation was underway, but at the time of the report, facility staff did not disclose that the incident had resulted in serious injury, harm, or death, even though they had knowledge of the resident’s death. During a face-to-face interview, the DON acknowledged the findings and made no comment.

Penalty

Inspection fine: $117,516

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to provide safe and appropriate respiratory care by not maintaining a required spare tracheostomy tube at the bedside for one resident with a tracheostomy. The facility’s policy titled “Unplanned Decannulation: Risk Assessment, Precautions and Interventions” dated 12/09/25 stated that a replacement airway must be kept at the bedside for all airway patients. The resident was admitted with multiple diagnoses including acute and chronic respiratory failure with hypoxia, chronic kidney disease, and hyperkalemia, and had a care plan for risk of respiratory complications related to COPD and respiratory failure. The resident’s MDS showed intact cognition (BIMS score 14) and documented that the resident received oxygen therapy, suctioning, and trach care. A physician’s order directed use of a Shiley trach, size 6.5 cuffless, with specified FiO2 and oxygen saturation parameters. During an observation, the resident was seen in her room in a wheelchair with a tracheostomy and speaking valve in place, and no spare trach tube was found anywhere in the room. The assigned LPN searched behind the bed, on the bed, and in the bedside drawers and confirmed there was no spare trach, stating she did not know the resident did not have one and suggesting it might be on the respiratory cart. In a subsequent interview, the Director of Respiratory Therapy stated that respiratory therapy is responsible for setting up and placing spare trachs and other emergency equipment, such as an Ambu bag, at the bedside for all airway patients except laryngectomy patients, and confirmed that all airway patients must have a spare trach at the bedside in case of accidental dislodgement. When instructed to verify the presence of a spare trach, the assigned respiratory therapist went to the resident’s room, searched, and reported there was no spare trach for the resident, stating he did not know why and that he had just arrived.

Penalty

Inspection fine: $117,516

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to demonstrate appropriate competencies and skill sets in providing safe emergency care to a resident who was a full code with a tracheostomy. The resident had multiple diagnoses including acute respiratory failure with hypoxia, epilepsy, dysphagia following cerebral infarction, diabetes mellitus, and schizophrenia, and received oxygen, tracheostomy care, and respiratory therapy services. During a night shift supervisor round at approximately 3:00 AM, the nurse supervisor found the resident on the floor near the doorway, lying supine, unresponsive, without a pulse or respirations, and with the inner cannula of the tracheostomy tube dislodged while the oxygen tubing remained connected. The nurse supervisor reported that she performed a brief assessment, checked for pulse and respirations, and initiated CPR. She stated she provided chest compressions for about three minutes but did not provide ventilations via the tracheostomy site using an Ambu bag or any other form of rescue breathing, despite the facility’s CPR policy referencing American Heart Association (AHA) guidelines that include providing breaths after chest compressions. Instead of immediately calling for help from the resident’s room, she left the unresponsive resident alone to run to the nurse’s station to get assistance, explaining that she did not use the call light or shout for help because it was 3:00 AM and she did not want to wake other residents. She further stated that she initially called a “Rapid Response” rather than a “Code Blue,” even though the resident was unresponsive, pulseless, and not breathing, and she had already been performing CPR without response. These actions were inconsistent with the facility’s Emergency Procedure – Cardiopulmonary Resuscitation policy, which directed staff to immediately activate the emergency response system (Code Blue), call 911, and provide CPR in accordance with AHA guidelines, including chest compressions and rescue breaths. The evidence showed that staff did not immediately activate a Code Blue, did not promptly call for help from the scene, and did not accurately provide CPR, specifically failing to provide ventilations via the tracheostomy site. The resident was later pronounced deceased at the hospital. Review of the nurse supervisor’s file showed she had been certified/trained in CPR/Basic Life Support using AHA guidelines, yet the care provided did not follow those guidelines. Facility staff also failed to ensure that another resident consistently received an ordered anticonvulsant medication, Lacosamide 200 mg, prescribed twice daily for seizure precaution. This resident had diagnoses including convulsions, hypertension, spastic hemiplegia affecting the left dominant side, and an active diagnosis of epilepsy with status epilepticus, and the care plan directed staff to give seizure medication as ordered and monitor effectiveness. A controlled substance record showed that the last available dose from one supply was administered on a specific date at 10:00 PM, with the count then at zero. The prescription for Lacosamide was written on a later date but was not faxed to the pharmacy until several days afterward, contrary to facility policy requiring refills to be reordered at least three days before the last dose. During the period when the resident should have been receiving Lacosamide, the Medication Administration Record (MAR) showed multiple entries where the medication was not administered, documented with codes indicating “hold/see progress notes” or “other/see progress notes.” On several later dates, an LPN documented on the MAR that Lacosamide 200 mg was administered at 10:00 PM, but there was no corresponding documentation that the medication had been removed from the Omnicell or delivered from the pharmacy, and the controlled drug disposition form showed no doses available after the earlier date. At the same time, Omnicell inventory records showed that six Lacosamide 200 mg tablets were in stock and available in the facility, yet they were not used for the resident. The resident experienced seizures, including one episode after smoking and another associated with a change in mental status, leading to rapid responses and transfers to the hospital. The physician was not made aware that the resident had missed multiple doses of Lacosamide, despite the missed administrations documented on the MAR.

Penalty

Inspection fine: $117,516

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to ensure controlled substances were properly reconciled by not signing controlled medication forms at the time medications were administered for three residents. For one resident with neuralgia, neuritis, hypertension, encephalopathy, severe cognitive impairment, and an order for PRN Tramadol 50 mg every six hours for right arm pain, a controlled substances reconciliation on Unit 2 East showed a discrepancy: the narcotic control sheet documented 2 tablets remaining, while the blister pack contained only 1 tablet. The LPN conducting the reconciliation stated that the medication had just been given and acknowledged forgetting to sign the controlled substance form when the dose was removed and administered. A second resident with pain, neuralgia, neuritis, muscle spasms, intact cognition, and an order for Pregabalin 150 mg twice daily for neuropathy pain also had a discrepancy during the same reconciliation on Unit 2 East. The controlled substance form showed 18 capsules remaining, but the blister pack contained 17, and the LPN reported forgetting to sign when the medication was given. A third resident with conversion disorder with seizures or convulsions, Crohn’s disease, dementia, severe cognitive impairment, and an order for Lacosamide 200 mg twice daily for seizures had a similar issue on Unit 3 West. During reconciliation, the controlled substance form indicated 18 tablets remaining, while the blister pack had 17 tablets; the RN stated that they were supposed to sign the narcotic sheet when pulling the medication to give to the resident, implying this had not been done. These findings showed that controlled substances were not consistently reconciled as required when administered.

Penalty

Inspection fine: $117,516

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to follow their policy for timely disposal of a controlled substance for one resident. The facility’s policy on discarding and destroying medications, dated 12/09/25, required that disposal of controlled substances occur immediately and no longer than three days after discontinuation. Resident #8, admitted with diagnoses including epilepsy, acute respiratory failure, and dysphagia, had a physician’s order for Lacosamide 100 mg tablets via PEG tube twice daily from 11/28/25 through 12/28/25. The medication was therefore discontinued on 12/28/25. On 02/26/26, the Administrator provided a list of residents currently prescribed and taking Lacosamide, and Resident #8 was not on that list. During a medication cart audit on Unit 2 East the same day, an LPN and the surveyor found 23 Lacosamide 100 mg tablets for Resident #8 stored in the narcotic box, despite the medication having been discontinued for 59 days. The LPN stated they did not know why the resident still had the medication and confirmed the resident was not receiving it. In a subsequent interview, the DON acknowledged that monthly cart audits were supposed to be done at the beginning of each month, was unsure if one had been done for January, and was not aware that Resident #8’s Lacosamide tablets were still on hand. As a result, the controlled substance was not disposed of within the timeframe required by facility policy.

Penalty

Inspection fine: $117,516

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to maintain accurate, resident-specific medical records when an LPN falsely documented administration of an anticonvulsant medication. A resident with diagnoses including convulsions, hypertension, and spastic hemiplegia had a physician’s order for Lacosamide 200 mg by mouth twice daily for seizure precaution. A quarterly MDS showed the resident had intact cognition (BIMS score 15), no rejection of care behaviors, an active diagnosis of epilepsy with status epilepticus, and receipt of anticonvulsant medications. The controlled drug receipt/record/disposition form for Lacosamide indicated that the last available dose was administered on 06/06/25 at 10 PM by the LPN, with a documented count of zero tablets remaining. Despite the controlled drug record showing no remaining tablets after 06/06/25, the June 2025 MAR showed that the same LPN documented administration of Lacosamide 200 mg to the resident on 06/07/25, 06/09/25, and 06/11/25 at 10 PM. Review of the Omnicell inventory for June 2025 showed six Lacosamide 200 mg tablets in stock and available in the facility, but there was no documented evidence that any Lacosamide tablets were removed from the Omnicell or delivered from the pharmacy corresponding to the doses charted on those dates. A facility-reported incident stated that, upon review of the controlled drug disposition form, the resident had not received the medication on the dates for which the LPN had signed the MAR, demonstrating that the LPN falsely documented administration of the Lacosamide doses.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to ensure resident records contained accurate information for two of seven sampled residents. For one resident admitted with multiple diagnoses including Gastrostomy Status, Dysphagia, Encephalopathy, and Acute Respiratory with Hypoxia, the record repeatedly documented a G-tube and G-tube feedings in nursing notes, while the history and physical documented a J-Tube and tube feeding per J-tube. During interview, the RN/Unit Manager stated the staff documented G-tube in error and that the resident had a J-tube, not a G-tube. For another resident admitted with dementia, a nursing note documented skin discoloration on the right cheek, while the initial assessment described discoloration on the top of the right eye and the care plan referenced discoloration on the right forehead. During interview, the RN/Unit Manager stated the nursing note was an error and that the resident had a bruise above the right eyebrow, not the right cheek.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to provide necessary respiratory care to a resident following the decannulation of her tracheostomy tube, as required by the resident's comprehensive care plan and the facility's policy. The resident, who had a history of tracheostomy, acute and chronic respiratory failure, and was at high risk for self-decannulation, was found by staff with her trach tube either partially or completely out on multiple occasions. Despite clear physician orders and care plan interventions outlining the steps to take in the event of decannulation—including calling a rapid response team, assessing airway patency, and ensuring only qualified practitioners reinsert the trach tube—these protocols were not followed. On the day of the incident, staff observed the resident with her trach tube either halfway out or completely out, with no signs of respiratory distress. Instead of calling a rapid response or respiratory therapist as required, nursing staff attempted to reinsert or adjust the trach tube themselves. Interviews revealed that the nurses involved did not check the resident's vital signs or airway patency before reinserting the tube, and did not perform hand hygiene prior to the procedure. The facility's Director of Respiratory confirmed that nurses are not trained or authorized to reinsert trach tubes, and that the established protocol was not followed in this case. Documentation and staff interviews further indicated that the nurse who performed the reinsertion did not have documented competency or training to be considered a qualified practitioner for this procedure. The incident was reported by a speech therapist who witnessed the event and expressed concern about the lack of proper protocol adherence. Although the resident did not suffer harm as a result of this deficient practice, the failure to follow established respiratory care protocols and the resident's care plan constituted a deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to demonstrate appropriate competencies and skills in providing safe nursing care for a resident with a tracheostomy. The resident, who had a history of self-decannulation and multiple respiratory diagnoses, was at high risk for airway complications. The care plan and facility policy required that, in the event of unplanned decannulation, a rapid response should be called and only a qualified practitioner, such as a respiratory therapist, should reinsert the tracheostomy tube. Despite these protocols, a registered nurse who was not trained or documented as a qualified practitioner reinserted the resident's tracheostomy tube after it was found dislodged. On the day of the incident, a speech therapist discovered the resident's tracheostomy tube had come out and notified nursing staff. Two nurses entered the room and one of them reinserted the tube without performing hand hygiene, checking vital signs, or assessing airway patency or oxygenation status. The resident showed signs of pain during the procedure. The nurse involved later confirmed that she did not follow the facility's protocol, did not call for a rapid response, and was not trained to reinsert a tracheostomy tube. Documentation and staff interviews confirmed that the nurse was not qualified to perform this procedure and that the required steps outlined in the resident's care plan and facility policy were not followed. The incident was reported by staff and confirmed through interviews and record review. The facility's Director of Respiratory and other leadership staff stated that only respiratory therapists or specifically trained staff are permitted to reinsert tracheostomy tubes, and that all nurses are instructed on the tube out procedure annually. However, there was no evidence that the nurse who performed the reinsertion had received the necessary training or competency validation. The resident did not suffer harm as a result of this incident.