Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mercy Harvard Hospital Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including chronic hypoxic respiratory failure, chronic bronchitis, atrial fibrillation, hypotension, pleural effusion, ostomy, prior CVA, and Alzheimer’s dementia, was assessed as high fall risk with care plan documentation of unsteady gait, impaired balance, and weakness. While the resident reported feeling very weak and short of breath and required one-person assist for transfers, a CNA transferred the resident to the toilet by lifting under the arms and pivoting without using a gait belt, contrary to facility policy requiring gait belt use for assisted transfers and ambulation. An RN confirmed the resident is a fall risk and that aides are expected to use gait belts for residents needing assistance to help keep them steady.
A resident with an order for fast-acting insulin received a dose from an insulin pen that had been opened and labeled with an expiration date more than two weeks past due. An RN prepared and administered 4 units of insulin from this pen without verifying the expiration date, despite the pen being clearly marked. The DON reported that staff are required to date insulin pens when opened, assign a 28-day beyond-use date per policy and manufacturer instructions, and verify dates before administration, with night nurses responsible for removing expired pens. The DON later explained that the 28-day limit exists because insulin loses efficacy over time.
A deficiency occurred when a CNA provided urinary incontinence and colostomy care to a resident with multiple chronic conditions, including chronic hypoxic respiratory failure, chronic bronchitis, atrial fibrillation, hypotension, pleural effusion, an ostomy, and Alzheimer’s dementia, without changing gloves or performing hand hygiene between dirty and clean tasks. While wearing the same pair of gloves, the CNA emptied and cleaned around the colostomy bag, removed soiled briefs and pants, applied clean clothing and a new brief, removed the resident’s mask, provided perineal care, and assisted the resident to a wheelchair. The CNA later acknowledged gloves should be changed between dirty and clean tasks, and an RN confirmed that facility practice is to change gloves and perform hand hygiene in such situations. The facility could not provide a policy addressing glove use during incontinence or colostomy care.
The facility failed to ensure the water system was flushed to prevent Legionnaire disease, affecting all 16 residents. Despite chlorinated water supply, daily flushing was not documented or consistently performed, and housekeeping staff lacked proper education and documentation on flushing procedures.
A resident with a history of dysphagia was not adequately supervised during meals, leading to coughing episodes and difficulty swallowing. Despite the resident's care plan requiring supervision and periodic checks, no staff were observed assisting her during the meal, resulting in a deficiency.
A resident was found with a dropped pill on her blanket after a nurse administered her morning medications. The pill was identified as her dose of eliquis, a blood thinner. The medication was signed out as given, and the resident's medical record did not indicate she could self-administer medications. The facility's policy requires authorized personnel to follow the 5 R's of medication administration.
Failure to Use Gait Belt During Transfer of High Fall-Risk Resident
Penalty
Summary
The deficiency involves staff failure to follow the facility’s gait belt policy when assisting a high fall-risk resident with transfers. The resident had multiple medical diagnoses, including chronic hypoxic respiratory failure, chronic bronchitis, atrial fibrillation, hypotension, pleural effusion, ostomy, left hemicolectomy, and Alzheimer’s dementia without behaviors. A fall risk assessment identified the resident as a high fall risk, and the care plan documented risk for falling due to unsteady gait, impaired balance, poor activity tolerance with continuous oxygen, prior CVA, and weakness. Despite these documented risks, the resident was assisted with a transfer without the use of a gait belt. During an observed transfer to the toilet, a CNA assisted the resident, who stated feeling very weak and having difficulty breathing, by lifting under the resident’s arms and pivoting the resident to the toilet without applying a gait belt. The CNA stated the resident was a one-person assist for transfers, acknowledged the resident’s weakness, but reported believing the resident was not really a fall risk and did not need a gait belt because the resident could stand independently. In contrast, an RN stated the resident is a fall risk, has been more incontinent, and will attempt to transfer to the toilet independently, and further stated that aides should use a gait belt for all residents requiring assistance to help keep them steady and prevent falls. The facility’s written policy required nursing staff to use a gait belt to assist residents with transfers and ambulation, stating that a gait belt allows a secure hold on the resident.
Expired Insulin Pen Administered Due to Failure to Verify Beyond-Use Date
Penalty
Summary
The facility failed to ensure pharmaceutical services were provided in accordance with manufacturer instructions and facility policy when nursing staff administered expired insulin to a resident. The resident had a physician’s order for fast-acting insulin, ranging from 0–12 units to be given at mealtimes. On the surveyor’s observation, an RN (V4) prepared the resident’s fast-acting insulin pen, which was labeled with a handwritten date indicating when it was first opened and a handwritten expiration date of “Exp 1/29.” Despite this labeling, V4 proceeded to prepare the insulin and injected 4 units into the resident’s right lower abdomen. The DON (V3) stated that when a new insulin pen is opened, nursing staff are expected to write the date opened and the expiration date on the pen, and that insulin pens typically expire one month after opening per manufacturer instructions. V3 further explained that night nurses are responsible for verifying insulin pen dates and disposing of expired pens, and that all nursing staff should verify insulin pen expiration dates prior to use. V3 acknowledged that V4 should have recognized that the insulin pen was more than two weeks past its labeled expiration date, discarded it, and obtained a new pen. The facility’s policy on vial and irrigation solution expiration dating specifies a 28-day beyond-use date for multiple-dose containers unless otherwise specified by the manufacturer, and the manufacturer’s instructions for the fast-acting insulin pen direct that it be thrown away after 28 days of use. V3 later stated that the one-month expiration date is due to the insulin losing efficacy over time.
Failure to Perform Hand Hygiene and Glove Changes During Incontinence and Colostomy Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (V5) failed to perform hand hygiene and change gloves while providing urinary incontinence and colostomy care to a resident (R1). R1’s electronic face sheet dated 2/18/26 documented multiple diagnoses including chronic hypoxic respiratory failure, chronic bronchitis, atrial fibrillation, hypotension, pleural effusion, ostomy, left hemicolectomy, and Alzheimer’s dementia without behaviors, and the care plan dated 6/4/25 indicated R1 was occasionally incontinent of urine and required incontinence care after each episode. On 2/17/26 at 12:55 PM, during provision of care, V5 applied clean gloves, emptied the resident’s colostomy bag, cleaned around the colostomy, removed the soiled incontinence brief and pants, applied clean pants and a clean incontinence brief, removed the resident’s surgical mask, applied a clean shirt, provided perineal care, and assisted the resident to a wheelchair without changing gloves or performing hand hygiene at any point. V5 later acknowledged that gloves should be changed when moving from dirty to clean tasks and attributed the failure to being nervous. On 2/18/26 at 1:02 PM, a registered nurse (V6) stated that staff should change gloves and perform hand hygiene when moving from dirty to clean tasks or when gloves are visibly soiled, and described an alternate sequence of care to avoid cross-contamination. The facility was unable to provide a policy regarding glove usage during incontinence or colostomy care.
Failure to Ensure Proper Water System Flushing
Penalty
Summary
The facility failed to ensure the water system was flushed to prevent Legionnaire disease, affecting all 16 residents. The facility manager acknowledged a recent low-level positive result for Legionella bacteria in an unoccupied resident room during quarterly testing. Despite the water supply being chlorinated, the positive result indicated that daily flushing of dead leg areas was not being properly documented or consistently performed. The outside water company representative confirmed that daily flushing for 15-20 minutes should prevent positive results, but the facility's housekeeping staff did not document this activity, and it was not included in their job descriptions or route sheets. Housekeeping staff reported running water while cleaning rooms but did not keep logs or receive documented in-service education on flushing procedures. The facility's policy on water system maintenance emphasized the importance of routine inspection and control measures, but there was no evidence of proper documentation or adherence to these procedures. The environmental service supervisor confirmed the lack of documentation and education, highlighting a significant gap in the facility's infection prevention and control program.
Failure to Supervise Resident with Dysphagia During Meals
Penalty
Summary
The facility failed to ensure a resident with a history of dysphagia was adequately supervised during meals and that the recommended swallowing strategies were implemented. The resident, a [AGE] year old female with diagnoses including aphasia, oropharyngeal dysphagia, type 2 diabetes, and progressive supranuclear palsy, was observed feeding herself minced chicken, puree sweet potato, and puree cauliflower. During the meal, the resident experienced coughing episodes, spit out pieces of chicken, and had a quarter size of food on her tongue. Despite these signs of difficulty, no staff were observed checking on her during the meal, and her coughing was audible from the hallway. Two CNAs were in the dining room, and an RN was in another resident's room at the time of the observation. The resident's care plan indicated she required supervision during meals and that staff should check her mouth for food residual and signs of aspiration. Interviews with staff confirmed that the resident likes to feed herself but requires supervision due to her condition. The Assistant Director of Nursing stated that staff should be checking on the resident every 5-10 minutes during meals to ensure she is eating without difficulty and to intervene if swallowing difficulties are noted. The facility's Swallowing Guidelines policy also supports this requirement. However, the lack of supervision and failure to implement the recommended swallowing strategies during the observed meal led to the deficiency noted in the report.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received significant medications as ordered by the physician. On April 8, 2024, a resident was found with a small round yellow pill, identified as her morning dose of eliquis (a blood thinner), lying on her blanket. The resident stated that the nurse had just given her the morning medications. The Registered Nurse confirmed that she had administered the medications and acknowledged that the pill must have been dropped. The medication administration report indicated that the medication was signed out as given, and the resident's medical record did not show that she could self-administer her medications. The facility's policy on medication administration specifies that only authorized personnel may administer medications and that they must follow the 5 R's of medication administration: Right Patient, Right Route, Right Dose, Right Time, and Right Medication.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 210 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Harvard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Hi Nursing Home | 8.8 mi | — | 1 | 0 |
| Florence Nursing Home | 12.1 mi | — | 0 | 0 |
| Symphony Maple Crest | 12.8 mi | — | 2 | 0 |
| Williams Bay Health Services | 13 mi | — | 1 | 0 |
| Hearthstone Manor | 13 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mercy Harvard Hospital Care Center.
100% money-back within 48 hours.
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.