Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harrington Park Health And Rehabilitation during CMS and state inspections, most recent first.
Illegible Expiration Dates on Aspirin Bottles: Two medication carts contained bottles of Aspirin 81 mg with expiration dates that could not be read. One CMA stated she only checks expiration dates when opening bottles, and another CMA admitted she administered the medication without checking the expiration date. The DON stated staff are expected to check carts daily and remove expired or illegibly labeled medications.
Infection control practices were not followed during care for multiple residents. A CMA used a shared BP monitor for two residents without sanitizing the device or the med cart between uses, a WCN applied a clean wound dressing without changing gloves after wound cleansing, and a CNA performed Foley catheter care without glove changes or hand hygiene while allowing cloths and towels to contact the bed, resident body, and catheter. The DON stated staff were expected to follow hand hygiene, glove use, and clean-to-dirty technique.
Bathroom ventilation vents in two resident rooms were found with grey, fuzzy debris on repeated observations. The logbook required exhaust fans to be checked and cleaned as needed, but a housekeeper said he had not cleaned the vents since working at the facility and that vents were expected to be dusted every other day. The Housekeeping Director and Administrator both confirmed housekeeping staff were responsible for dusting and cleaning vents as part of room cleaning duties.
Incorrect PASRR Screening on Admission: A resident with bipolar disorder, depression, and moderate cognitive impairment had an inaccurate Level I in the EMR that did not reflect his psychiatric diagnoses or trigger a Level II referral. The SSD confirmed the resident should have had a PASRR Level II and acknowledged the initial Level I was not completed correctly.
A resident with severe cognitive impairment was found with unsecured medicated Vapor Rub at their bedside, without being assessed for self-administration of medication. Facility staff were unaware of any care plan allowing self-administration, and the Administrator confirmed that no residents had been assessed to self-medicate safely, highlighting a failure in policy adherence.
The facility failed to implement care plans for two residents with contractures, as required by their medical needs. Both residents had care plans that included the use of splints to maintain range of motion and prevent worsening of contractures. However, observations revealed that the splints were not applied, and were instead found on the bedside nightstands. The DON acknowledged the care plans were not being followed.
Two residents with contractures were not provided with their prescribed splints, as observed on multiple occasions. Despite care plans indicating the necessity of splints to prevent worsening of contractures and maintain range of motion, the splints were found on the nightstand instead of being applied. Staff interviews confirmed the oversight, leading to a deficiency in care.
Illegible Expiration Dates on Aspirin Bottles
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles when two bottles of Aspirin 81 mg on two sampled medication carts had illegible expiration dates. During observation of medication storage, a CMA showed a bottle of Aspirin 81 mg with an expiration date that could not be read, and the CMA stated she only checks expiration dates when opening bottles and placing an open date on them. She acknowledged she was not supposed to give medication from that bottle and should have discarded it. A second medication cart also contained a bottle of Aspirin 81 mg with an illegible expiration date. The CMA responsible for that cart stated she checked the cart daily but had not noticed the illegible expiration date, and she admitted she administered the medication that morning without checking the expiration date. The DON stated staff are aware they should check medication carts daily and remove expired medications or medications with illegible expiration dates, and that the unit nurse is also responsible for checking the carts as a second set of eyes.
Infection Control Practices Not Followed During Resident Care
Penalty
Summary
Basic infection control practices were not followed while caring for four sampled residents, including R16, R13, R32, and R6. The facility’s policies on hand hygiene, infection prevention and control, infection prevention plan, and Foley catheter care stated that hand hygiene, standard precautions, clean-to-dirty technique, and proper glove use were required to prevent the spread of infection and to reduce infection risk during resident care. During medication pass, a CMA assessed blood pressure for R32 using a shared blood pressure monitor, left the room, placed the monitor on the medication cart, sanitized her hands, and then entered R6’s room with the same monitor. The monitor and medication cart were not sanitized between residents, and the CMA then removed medications from the cart and prepared them for administration. The CMA later confirmed she did not sanitize the shared blood pressure cuff between resident use and stated she should have cleaned the device after each resident and should not have placed it on the cart without cleaning it. During wound care, the WCN sanitized her hands, donned gloves, removed the soiled dressing, doffed gloves, performed hand hygiene, and then donned gloves again to clean the wound. She then placed the clean dressing onto the wound bed while wearing the same gloves used for cleaning, without a glove change or hand hygiene before applying the clean dressing. During catheter care, a CNA used cloths and a towel in a manner that allowed them to sweep across the bed, the resident’s body, the leg, and the catheter, did not fold the cloths around her hand, did not change gloves, and did not perform hand hygiene during the process. The CNA also returned the resident’s belongings to the table without sanitizing it. The WCN and CNA both confirmed the practices observed.
Bathroom Ventilation Vents Not Kept Clean
Penalty
Summary
The facility failed to maintain a clean and homelike environment by allowing bathroom ventilation vents to remain covered with grey, fuzzy debris in two resident rooms on [NAME] Hall. Review of the logbook for exhaust fan maintenance showed that vents were to be checked for proper operation and cleaned as needed, including cleaning vents with a vacuum and air compressor when necessary to remove dust. However, observations in both rooms on multiple occasions showed the bathroom ceiling vents with visible debris. During interview and observation, a housekeeper stated he had worked at the facility for about four months, that his duties included cleaning resident rooms and dusting vents, and that vents were expected to be dusted every other day. He observed the vents in both rooms and stated they appeared dusty; he also stated he had not cleaned those vents since working at the facility and that one may need to be changed out. The Housekeeping Director observed dust accumulation and stated housekeepers were expected to dust daily and touch and clean everything in the room while cleaning. The Administrator confirmed housekeeping staff were responsible for cleaning resident rooms and that vents should be included on the checklist of duties.
Incorrect PASRR Screening on Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed correctly for one resident, R54, upon admission. The facility policy required review of PASRR for all new admissions and follow-up if a Level I or Level II could not be located in the EMR. R54 was admitted with diagnoses including chronic obstructive pulmonary disease, chronic kidney disease stage 3b, bipolar disorder unspecified, and depression, and his quarterly MDS showed a BIMS score of 11, indicating moderate cognitive impairment. His physician orders included Buspirone for bipolar disorder unspecified, Celexa for depression unspecified, and Wellbutrin XL for bipolar disorder unspecified. Record review showed a Level I in the EMR dated 04/02/2025 that did not reflect his diagnoses of bipolar disorder, depression, or anxiety and therefore did not indicate the need for specialized services or referral for a Level II. The SSD stated that R54’s bipolar disorder and depression would have made him eligible for a PASRR Level II, confirmed these diagnoses were present on admission, and acknowledged she was not aware he had a Level II. She also stated that R54 should have had a PASRR Level II and that he fell through the cracks. The SSD further admitted the initial Level I was not completed correctly and was unsure whether she had submitted it.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medications, as required by their policy. The resident, identified as R208, was admitted with multiple diagnoses, including severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. Despite this, a container of medicated Vapor Rub was observed on the resident's bedside table on two separate occasions, suggesting that the resident had access to unsecured medication without proper assessment or authorization. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policy on self-administration of medications. The Licensed Practical Nurse (LPN) Wound Care Nurse confirmed that there was no care plan allowing the resident to self-administer medications and subsequently removed the Vapor Rub from the resident's room. The facility's Administrator confirmed that no residents had been assessed to self-medicate safely, and all medications should be secured, indicating a failure in policy implementation and oversight.
Failure to Implement Care Plans for Residents with Contractures
Penalty
Summary
The facility failed to implement the care plans for two residents, R21 and R36, as required by their medical needs. R21 was admitted with multiple diagnoses, including hemiplegia, dysphagia, and contractures. The care plan for R21 included the use of a splint to maintain the range of motion and prevent worsening of contractures. However, observations on two separate occasions revealed that R21 was not wearing the splint, which was instead found on the bedside nightstand. Similarly, R36, who was admitted with conditions such as hemiplegia, diabetes, and contractures, had a care plan that required the use of a splint to prevent the worsening of contractures. Observations showed that R36 also did not have the splint applied, with it being left on the nightstand. The Director of Nursing acknowledged that the care plans were not being followed for both residents.
Failure to Apply Splints as Ordered
Penalty
Summary
The facility failed to ensure that splints were applied as ordered by the physician for two residents, leading to a deficiency in maintaining and improving their range of motion and mobility. Resident 21 was admitted with multiple diagnoses, including hemiplegia, contractures, and hypertension, and was dependent on staff for all activities of daily living. The care plan for Resident 21 indicated the use of a splint to the left hand to prevent worsening of contractures. However, observations on two consecutive days revealed that the splint was not applied, and it was found lying on the bedside nightstand instead. Similarly, Resident 36, who had severe cognitive impairment and required extensive assistance, was also observed without the prescribed splint on two separate occasions. The care plan for Resident 36 included the use of a splint to manage contractures and maintain range of motion. Despite this, the splint was not applied, and it was found on the nightstand. Interviews with staff confirmed that the splints should have been applied daily, but they were not, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Place At Martinez, The | 0.3 mi | ★★★★★ | 17 | 0 |
| Harborview Health Center Of Augusta | 1.2 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Richmond, Llc | 1.8 mi | ★★★★★ | 1 | 0 |
| Stevens Park Health And Rehabilitation | 2.3 mi | ★★★★★ | 5 | 0 |
| Pavilion At Brandon Wilde | 3 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.