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Complaint Investigation

Harbor Health & Rehab

February 25, 2026 · East Chicago, IN · 5025 Mccook Ave
Citations 5
CMS Rating 1/5
Beds 106
Provider ID 155653
Healthcare Facility
Harbor Health & Rehab
East Chicago, IN  ·  View full profile →
Inspection Summary

HARBOR HEALTH & REHAB in EAST CHICAGO, IN — inspection on February 25, 2026.

Found 5 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0580
Resident Rights Deficiencies

During an interview on 2/24/26 at 10:25 a.m., the Director of Nursing did not notify the Responsible Party of the roommate change, she was under the impression notification was only to be reported for a room change.

She was now educating the staff to notify appropriate parties when a new roommate is brought in.

This citation relates to Intake 2739564. 3.1-5(b)(1) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

155653 02/25/2026

Harbor Health & Rehab 5025 McCook Ave East Chicago, IN 46312

Investigation was initiated.A Care Plan, dated 8/2/24 and revised on 2/10/26, indicated the resident was at risk for abuse and neglect.

Interventions included, but were not limited to, assuring the resident that they were in a safe environment, and reporting abuse per policy.The abuse/neglect care plan interventions were last revised on 8/2/24.A Care Plan, dated 9/5/24 and revised on 12/11/25, indicated the resident displayed socially inappropriate and maladaptive behavior.

Interventions included, but were not limited to, exercising the resident at regular intervals, report behaviors to psych services, and use frequent reassuring phrases.The socially inappropriate/maladaptive behavior care plan interventions were last revised on 9/14/25.During an interview on 2/25/26 at 1:37 p.m., the Director of Nursing, Nurse Consultant, and Administrator indicated the interventions should have been updated and they understood the concern.

They had no additional information to provide. 4.

The record for Resident E was reviewed on 2/25/26 at 11:09 a.m.

Diagnoses included, but were not limited to, hemiplegia (one side of the body has paralysis), hypotension (low blood pressure), paranoid schizophrenia, aphasia (difficulty talking), epilepsy, dysphagia (difficulty swallowing), and contracture of the right hand.A facility reported incident, dated 12/26/25, indicated Resident E had displayed aggressive behavior toward Resident D.

Head to toe assessments were done on both resident's and no injuries were noted.

The physician and the family were notified.

Resident D was sent out to the hospital for evaluation.A Care Plan, dated 5/21/24 and revised on 12/28/25, indicated the resident was at risk for abuse/neglect.

Interventions included, but were not limited to, assuring the resident knew they were safe, and reporting abuse per policy.The abuse/neglect care plan interventions were last revised on 5/21/24.A Care Plan, dated 5/7/24 and revised on 12/28/25, indicated the resident had paranoid schizophrenia.

Interventions included but were not limited to, refer to psych services and observe for mood/behaviors related to paranoid schizophrenia and develop interventions for dealing with them as needed.The schizophrenia care plan interventions were last updated on 5/7/24.This citation relates to Intakes 2739564 and 2742394.3.1-35(a)

155653 02/25/2026

Harbor Health & Rehab 5025 McCook Ave East Chicago, IN 46312

reviewed, and revised by a team of health professionals.

of 3 residents reviewed for care planning. (Resident B)Finding includes:The record for Resident B was

disorder, hypertension (high blood pressure), depression, anemia (low iron), depression, and COPD.The Quarterly Minimum Data Set (MDS) assessment, dated 11/4/25, indicated Resident B was cognitively impaired for daily decision making.A Social Services Note, dated 9/23/25, indicated the Social Service Director (SSD) had called to schedule a care plan meeting with the resident's daughter.

She had stated she was on her way to visit her father and could have the meeting when she arrived at the facility.

The SSD indicated she was free to conduct the meeting when she arrived.The resident's last Care Plan Meeting was on 9/23/25.There was no documentation indicating a care plan meeting had occurred after 9/23/25.

During an interview on 2/24/26 at 11:33 a.m., the Nurse Consultant indicated she had called the previous social worker to see if she could provide any input on why there was no documentation of a scheduled or rescheduled care plan meeting. At 4:11 p.m., the nurse consultant indicated the care meeting should have been documented as rescheduled if it was scheduled and cancelled.This citation relates to Intake 2739564. 3.1-35

155653 02/25/2026

Harbor Health & Rehab 5025 McCook Ave East Chicago, IN 46312

were just random.

She indicated the resident was recently in the behavioral unit in the hospital for a

have a de-escalation technique that worked for him.

Once [Resident C] gets started he doesn't stop

verbally aggressive to residents with nothing triggering him.

During an interview on 2/24/26 at 12:03 p.m., CNA 2 indicated Resident C had called her a b***h and slapped her across the face on 12/24/25.

He was not provoked in any way.

The facility called the police and the resident was taken to the behavioral hospital since she did not press charges.

During an interview on 2/25/26 at 10:31 a.m., the Director of Nursing indicated the resident did not strike any residents prior to his 12/24/26 admission but he did slap a staff member.

Resident C was not on 15-minute safety checks when he returned back from his two psychological evaluations at the hospital.

She reported he did not get placed on them again until he returned from the behavioral hospital this last time on 2/12/26, he had 1:1 supervision for 72 hours and had been on 15-minutes safety checks since.This citation relates to Intakes 2739564 and 2742394.3.1-37(a)

155653 02/25/2026

Harbor Health & Rehab 5025 McCook Ave East Chicago, IN 46312

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in accordance with accepted professional standards.

complete related to 15 minute safety checks for residents who had behaviors for 1 of 4 residents

at 2:47 p.m.

Diagnoses included, but were not limited to, schizophrenia, dementia, dysphagia (difficulty swallowing), depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse.The Quarterly Minimum Data Set (MDS) assessment, dated 11/4/25, indicated Resident C was cognitively intact for daily decision making.

Verbal behaviors were exhibited and the resident's current behavior was worse than the previous assessment.A Physician's Order, dated 2/16/26, indicated to initiate 15-minute safety checks every shift for monitoring.Safety logs were observed on the second floor and Resident C's 15-minute safety checks were not signed out from 3:00 p.m. to 4:00 p.m. on 2/24/26.

During an interview on 2/24/26 at 4:15 p.m., LPN 2 indicated she should have charted the 15-minute checks after she performed them but she hadn't had a chance to do so.

During an interview on 2/24/26 at 4:46 p.m., the Director of nursing indicated she would expect her nursing staff to complete the 15-minute safety checks on all the residents who had them on the unit and then sign off in their logs each time it was completed.

She acknowledged the 15-minute safety checks should have been signed off for the previous hour.This citation relates to Intakes 2739564 and 2742394.3.1-50(a)(2)

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EAST CHICAGO, IN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HARBOR HEALTH & REHAB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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