Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harvard Rest Haven during CMS and state inspections, most recent first.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility did not inform residents or their representatives of the benefits, risks, and alternatives before starting psychotropic meds for multiple residents. Records showed antipsychotic, antidepressant, and antianxiety meds were given before psychoactive consent was completed, and the consents that were later signed did not consistently include benefits, alternatives, or specific target behaviors. The FA and ADON confirmed the consents were not completed at the correct time and were missing required information.
MDS assessments were coded inaccurately for 3 residents. One resident was coded as receiving an injection when the MAR, TAR, orders, and notes showed none were given, while two residents were coded as not receiving anticonvulsants even though orders and MARs showed they received Lamotrigine, Levetiracetam, or Gabapentin as ordered. The ADON and IDON confirmed the coding errors.
Incomplete Care Plan for Resident with Schizophrenia and Psychotropic Medication Use: A resident admitted with Bipolar Disorder and Schizophrenia had an MDS showing use of an antipsychotic, antianxiety, and antidepressant medication, but the CCP only addressed antipsychotic-related adverse reaction risk. The care plan did not address the resident’s Schizophrenia, antidepressant use, or anti-anxiety medication needs, and the ADON and DON confirmed the plan was not comprehensively completed.
Expired Lantus was found in the locked med storage refrigerator for a resident. Surveyors observed an opened vial labeled with the resident's name and a discard date that had passed. RN-A and the Interim DON both confirmed the insulin was expired and should have been discarded after 28 days of use.
A resident did not sign the SNF ABN and NOMNOC until after the UR committee determined the LCD had ended and after the resident was expected to pay out of pocket. Record review showed there was no documentation that the resident or resident representative was informed of the LCD when it was determined, and the SSD confirmed the forms were signed after Medicare coverage had already ended.
A resident was discharged, but the facility did not notify the ombudsman of the discharge. Record review showed the ombudsman notification log only included hospital transfers, and the SSD confirmed the facility did not notify the ombudsman for discharges to home or transfers to another nursing facility.
Insulin Pen Not Held Per Manufacturer Directions: An RN failed to hold an insulin pen in place for 6 seconds while administering insulin to two residents, instead removing the pen immediately after injecting the dose. The RN stated they were unaware of the FlexPen instructions, and the IDON stated the facility had no policy or procedure to ensure insulin pen administration was performed correctly.
Failure to change a resident’s O2 tubing as ordered. Facility policy required tubing replacement every 2 weeks and storage in a mesh bag when not in use. Surveyors observed the tubing loose on the concentrator at times and dated beyond the ordered change interval, while the ADON and Interim DON confirmed the tubing should be changed every 14 days and kept in the mesh bag.
Incomplete Annual Training for Medication Aides: The facility failed to ensure required annual continuing education was completed for multiple medication aides. Record review showed that three medication aides completed less than the required 12 hours of training, and the IP nurse confirmed that multiple staff members were not current on their continuing education hours.
A facility failed to accurately document a resident's use of CPAP and oxygen therapy in the MDS. The resident, diagnosed with Obstructive Sleep Apnea and COPD, used a CPAP machine and had an order for oxygen therapy, but these were not reflected in the MDS. The ADON confirmed the oversight in the annual assessment.
A facility failed to include the use of a CPAP machine and oxygen concentrator in a resident's care plan, despite the resident's diagnoses of Obstructive Sleep Apnea and COPD. Observations confirmed the presence of these devices in the resident's room, and the resident confirmed their use at night. The ADON acknowledged the oversight, which did not align with the facility's policy for comprehensive care planning.
A facility failed to ensure a resident was evaluated by a provider before renewing a PRN antipsychotic medication, Seroquel. The resident, with multiple mental health diagnoses, had PRN orders renewed without the required evaluations. Records showed gaps in documentation and no evidence of evaluations on renewal dates, violating facility policy and regulatory requirements.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents or their resident representatives of the benefits, risks, and alternatives before starting psychotropic medications for 3 of 5 residents reviewed. The report states that the facility policy required residents, families, and/or resident representatives to be informed of the benefits, risks, alternatives, and black box warnings before a psychotropic medication was initiated or increased, but the medical records reviewed did not show that this occurred for the affected residents. For one resident with diagnoses of anxiety, bipolar disorder, and depression, the record showed administration of clonazepam, quetiapine, and sertraline after admission, but there was no consent or education in the chart before these medications were started. A later psychoactive medication consent was completed months after admission and listed the medications and some risks, but it did not include information about alternate treatments and did not clearly identify all conditions being treated. The FA confirmed that the consent was not completed before the medications were administered and that the form did not address alternate treatments and non-pharmacological interventions. For another resident admitted with bipolar disorder and schizophrenia, the record showed administration of citalopram, paliperidone, quetiapine, and trazodone during the look-back period, while the psychoactive medication consent was signed after the medications had already been started. The consent listed the medications and target behavior as depression, but it did not include the benefits of the medications, alternative treatment options or choices, or the specific targeted behaviors. For a third resident, the MDS and order summary showed sertraline and aripiprazole among the medications ordered, and the psychoactive consent was signed by the POA and FA without noted benefits or alternatives; the ADON and Interim DON confirmed there were concerns that psychotropic consents were not being completed and that the original consent on admission was not completed.
MDS assessments were coded inaccurately for medications
Penalty
Summary
The facility failed to code the MDS accurately for 3 of 3 sampled residents by not reflecting the medications actually provided during the look-back periods. For Resident 5, the Comprehensive MDS coded one injection in Section N0300, but physician orders, the MAR, the TAR, and progress notes for the month reviewed did not show any injectable medication or injection during the look-back period. The ADON, who also served as the MDS Coordinator, and the IDON both confirmed that Resident 5 did not receive an injection and that the MDS was coded incorrectly. For Resident 7, the Comprehensive MDS coded that no anticonvulsant medication was received in Section N0415, yet physician orders and the MAR showed Lamotrigine 225 mg twice daily and Levetiracetam 250 mg twice daily were administered during the look-back period. For Resident 17, the Quarterly MDS also coded no anticonvulsant medication in Section N0415, but physician orders and the MAR showed Gabapentin 800 mg three times daily was administered every day during the look-back period. In both cases, the ADON and IDON confirmed the residents received the anticonvulsant medications as ordered and that the MDS assessments were coded incorrectly.
Incomplete Care Plan for Resident with Schizophrenia and Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 7’s identified care needs. Resident 7 was admitted with diagnoses of Bipolar Disorder and Schizophrenia, and the comprehensive MDS showed the resident received an antipsychotic medication, an antianxiety medication, and an antidepressant medication during the 7-day look-back period. The facility policy titled Comprehensive Care Plans stated that the CCP should include measurable objectives and timetables to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Review of Resident 7’s care plan showed a focus on risk for adverse reactions related to daily antipsychotic use due to mental illness, with interventions addressing medication review, communication among prescribers, monitoring for adverse drug reactions, provider review, and pharmacy consultant recommendations. However, the care plan did not address the resident’s use of antidepressant and anti-anxiety medications, and it did not address the diagnosis of Schizophrenia or the related risks and interventions. During interview, the ADON and the Interim DON confirmed that the care plan did not comprehensively identify the resident’s care needs and did not address the diagnosis of Schizophrenia or the risks related to the antidepressant medication.
Expired Insulin Stored for a Resident
Penalty
Summary
The facility failed to ensure an expired insulin vial was disposed of and not used for Resident 16. During observation of the locked medication storage room refrigerator, surveyors found an opened vial of Lantus labeled with Resident 16's name and a discard date written on the label. Record review of facility guidance for Lantus stated that the vial should be discarded 28 days after opening or first use. In interview, RN-A confirmed that opened insulin should be discarded 28 days after opening and that the vial for Resident 16 had an expiration/discard date that had passed and should have been discarded. The Interim DON also confirmed that Resident 16's Lantus vial was expired and should not have been in use.
Late Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to ensure that Resident 32 signed the SNF ABN and NOMNOC before the facility determined that Medicare coverage had ended. Record review showed the facility’s admission agreement stated that if Medicare Part A SNF benefits were used, the facility would bill Medicare for covered services, and if Medicare would not pay because the resident did not require a Medicare Part A SNF level of care, the facility would provide a NOMNOC explaining that the stay would not be paid by Medicare and that the resident would be responsible for financial costs incurred during the continued stay. Record review showed the UR Committee met and determined Resident 32’s last covered day was 03/07/2026, but there was no documentation that the resident or resident representative was informed of that date at that time. The SNF ABN and NOMNOC were both provided to and signed by Resident 32 on 03/09/2026, after the last covered day and after the date the resident was to pay out of pocket. The SSD confirmed in interview that the resident signed both forms after the LCD and the date the resident was to pay out of pocket.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the ombudsman of a resident discharge for Resident 28, who was admitted to the facility and later discharged on 04/14/2026. Record review of the ombudsman notifications sent on 03/11/2026, 04/03/2026, and 05/06/2026 showed no documentation that the ombudsman was notified of this resident’s discharge. The notification record indicated that the ombudsman was only notified of hospital transfers. During interview, the Social Services Director stated that there was no notification to the ombudsman for Resident 28’s discharge and confirmed that the facility only notified the ombudsman of hospital transfers, not discharges to home or transfers to other nursing facilities.
Insulin Pen Not Held in Place Per Manufacturer Instructions
Penalty
Summary
Staff failed to administer insulin per manufacturer directions for two residents receiving insulin by pen device. A record titled Injection FlexPen dated 02/2023 stated the needle should be kept in the skin for at least 6 seconds while the push button remains fully depressed to ensure the full dose is administered. During observation of insulin administration, RN-A prepared the insulin pen by wiping the tip, applying a needle cap, dialing and expelling 2 units into the cap, then dialed 4 units for Resident 10 and injected the insulin into the resident's arm. RN-A immediately removed the pen from the resident's arm and did not hold it in place. The same process was observed for Resident 6, with RN-A dialing 6 units and injecting the insulin into the resident's abdomen, then immediately removing the pen without holding it in place for 6 seconds. During interview, RN-A stated they were unaware that the manufacturer instruction for the FlexPen required holding the device in place for 6 seconds with the push button depressed to ensure the full dose was administered. The Interim DON stated the facility did not have a policy or procedure for insulin administration using an insulin pen to ensure it was performed correctly and that residents received the prescribed dose. RN-A later reviewed the manufacturer instructions and confirmed the pen should have been held in place for 6 seconds, and acknowledged that this was not done as outlined in the instructions for use.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
Facility staff failed to change Resident 2’s oxygen tubing as ordered. The facility policy stated oxygen tubing would be replaced every two weeks by nursing staff and, when oxygen was not in use, the tubing should be placed in the mesh bag provided. Resident 2’s order summary directed staff to change the O2 tubing on night shift every 14 days. The administration record showed the tubing was changed on 05/15/2026, but multiple observations found the tubing still dated 05/08/2026, including times when it was loose on the concentrator and not in the mesh bag, and other times when it was in the mesh bag but still dated 05/08/2026. On 05/27/2026, the tubing was observed in the mesh bag and dated 05/26/2026. The ADON and Interim DON confirmed the expectation that the tubing should be in a mesh bag and changed every 14 days, and the ADON visually confirmed the tubing in the room was dated 05/08/2026.
Incomplete Annual Training for Medication Aides
Penalty
Summary
The facility failed to ensure that nurse aides and medication aides completed the required 12 hours of ongoing annual training. Record review showed that Medication Aide-E completed only 8.5 hours of continuing education during the applicable annual period, Medication Aide-F completed only 6.4 hours, and Medication Aide-G completed only 9.5 hours. The facility census was 23. During interview, the Infection Prevention Nurse confirmed that multiple staff members were not up to date on the required continuing education hours, including the staff members identified in the record review.
Inaccurate MDS Documentation for Respiratory Treatments
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, specifically regarding the use of Continuous Positive Airway Pressure (CPAP) and oxygen therapy. The resident, who was admitted with diagnoses of Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease (COPD), was observed to have a CPAP machine and an oxygen concentrator in their room. Despite this, the MDS did not reflect the use of these respiratory treatments, as the relevant sections for oxygen therapy and non-invasive mechanical ventilation were not checked. Interviews and record reviews revealed that the resident used a CPAP machine every night and had an order for oxygen at 2 liters per nasal cannula at bedtime when not using the CPAP. The Assistant Director of Nursing (ADON) confirmed that the MDS was an annual assessment and acknowledged that the sections for oxygen therapy and non-invasive mechanical ventilation were not marked as being used, indicating a failure to accurately document the resident's treatment needs.
Failure to Include CPAP and Oxygen Use in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 13, who was using a Continuous Positive Airway Pressure (CPAP) machine and an oxygen concentrator. The care plan, dated 2/11/25, did not include any focus, goals, or interventions related to the usage of the CPAP or oxygen, despite the resident's diagnoses of Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease (COPD). This omission was confirmed through record reviews, observations, and interviews. Observations on 2/24/25 and 2/25/25 revealed the presence of a CPAP machine and an oxygen concentrator in Resident 13's room. An interview with the resident confirmed the use of these devices at night. The Assistant Director of Nursing (ADON) acknowledged that the care plan should have addressed the resident's oxygen and CPAP usage, indicating a lapse in the facility's adherence to its policy of developing person-centered care plans that meet professional standards of quality.
Failure to Evaluate Resident Before Renewing PRN Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was evaluated by a provider prior to the renewal of an as-needed antipsychotic medication, Seroquel. The resident, who had diagnoses including dementia, paranoid personality disorder, delusional disorder, depression, and anxiety, was receiving Seroquel 25 mg by mouth at various dosages and frequencies, including a PRN order. The facility's policy required that PRN orders for antipsychotic medications be limited to 14 days, with a new order necessitating an evaluation by the attending physician or prescribing practitioner. A review of the resident's records revealed multiple instances where the PRN Seroquel was renewed without an evaluation. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed orders for Seroquel with start and end dates, but there were gaps in documentation regarding evaluations. Specifically, there was no record of an evaluation on the dates when the PRN Seroquel was ordered, and the Assistant Director of Nursing confirmed the absence of in-person or telehealth evaluations on those dates. The resident's progress notes and electronic health records indicated that faxes were sent to the psychiatric nurse practitioner requesting renewals of the PRN Seroquel, but there was no evidence of a corresponding evaluation. The resident had appointments with the psychiatric nurse practitioner, but these did not coincide with the dates of the PRN medication renewals. This lack of evaluation before renewing the PRN order for Seroquel constituted a failure to adhere to the facility's policy and regulatory requirements.
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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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Nursing homes near Harvard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sutton Community Home, Inc. | 12.2 mi | ★★★★★ | 10 | 0 |
| Good Samaritan Society - Hastings Village | 14.8 mi | ★★★★★ | 2 | 0 |
| Westfield Quality Care Of Aurora | 17.5 mi | ★★★★★ | 1 | 0 |
| Memorial Community Care | 17.7 mi | ★★★★★ | 4 | 0 |
| Legacy Square | 18.5 mi | ★★★★★ | 10 | 1 |
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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 August 2026) and official state health department websites.