Inspection Reports for Harbor Haven Health & Rehabilitation

Based on staff and resident interviews and record review, the facility did not ensure effective pain management for Resident R218. The complaint was substantiated with findings of inadequate follow-up assessments and interventions for acute left hip pain.

The facility did not ensure effective pain management for Resident R218 from 12/21/23 through 12/26/23. Despite documented pain and medication orders, follow-up assessments and non-pharmacological interventions were lacking, and physical therapy was not involved to evaluate transfer status. The resident was later transferred to the hospital with a left hip fracture.

The visit was complaint-related focusing on the accessibility of call lights for Resident 24. The complaint was substantiated with findings that the call light was not accessible and no specific call light assessment was completed.

The facility failed to ensure that call lights were within reach for Resident 24, as the call light was located behind an armoire and was not easily accessible. Staff interviews confirmed lack of awareness and no specific call light assessment was completed for R24.

The complaint investigation found that the facility did not timely report resident-to-resident altercations involving residents R1, R2, R4, and R5 to the State Agency within required timeframes. The incidents included altercations on 2/11/23 and 12/24/22, with delayed reporting to the State Agency and incomplete reporting to facility administration. The facility provided re-education to only one nurse regarding timely reporting requirements.

The facility failed to ensure timely reporting of multiple resident-to-resident altercations involving four residents to the State Agency and facility administration, despite policies requiring immediate reporting within 24 hours. Investigations revealed delays in reporting incidents occurring on 2/11/23 and 12/24/22, with staff re-education limited to only one nurse.