Harmar Place Nursing and Rehabilitation

Inspectors wroteBased on daily staffing assignment review, time & attendance detail report review and interview, the facility failed to ensure they provided eight consecutive hours of registered nurse (RN) coverage a day. This affected all 73 residents residing in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to maintain an effective pest control program. This affected three residents (#13, #22, and #30) of four residents reviewed and had the potential to affect 45 residents. The facility census was 73.

Inspectors wroteBased on closed medical record review, policy review, and interview, the facility failed to timely report and provide adequate, necessary and timely care for Resident #72 following a fall during a staff assisted transfer resulting in a delay of treatment for newly diagnosed compression vertebra fractures. This affected one resident (#72) of three residents reviewed for accidents. The census was 71. Actual Harm occurred on 05/06/25 at approximately 9:00 A.M. when Certified Nurse Assistant (CNA) #34 failed to notify the licensed nurse that Resident #72 sustained a fall during a staff assisted transfer resulting in a delay in treatment. The resident complained of back pain (intermittent, aching, moderate pain with protective body movements/posture associated with the pain) following the incident. However, the resident was not transferred to the hospital until 2:30 P.M. [...]

Inspectors wroteBased on observation, medical record review, policy review, and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program to ensure fall interventions were implemented for Resident #28 and to ensure Resident #72 and Resident #75 were provided adequate assistance with transfers. This affected three residents (#28, #72, and #75) of three residents reviewed for accidents. The census was 71. Actual Harm occurred on 05/06/25 at approximately 9:00 A.M. [...]

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to notify the physician and responsible party of a resident change in condition. This affected one resident (#72) of three residents reviewed. The census was 71.

Inspectors wroteBased on closed medical record review, review of emergency responder record, hospital record review, facility policy and procedure review and interview, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #26. The facility failed to ensure changes in the resident's medical condition were timely identified and comprehensive and individualized interventions were implemented for Resident #26 when the resident was assessed to have a decline in health including tachycardia, shortness of breath, fatigue, and weakness. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE] when Resident #26 had increased weakness and need for assistance with activities of daily living (ADLs) during therapy treatment. [...]

Inspectors wroteBased on observation, record review, policy review and interview the facility failed to ensure residents were properly assessed, monitored, and provided adequate nutrition to prevent weight loss. This affected three residents (#5, #7, and #69) of five residents reviewed for nutrition. Actual harm occurred on 01/29/25 when Resident #5, who required staff set-up assistance with meals was assessed to sustain a 12.1 pound severe weight loss (in approximately 30 days) as a result of the facility's failure to revise and/or implement comprehensive and individualized care plan interventions to address changes in the resident's nutritional status (decrease in oral intake) and impaired wound healing (of a Stage III pressure ulcer). [...]

Inspectors wroteBased on review of the water management (Legionella) control plan, review of the infection control log, review of CMS QSO memo, observation, interview, and policy review the facility failed to ensure infection control practices were maintained to prevent the spread of infectious disease and failed to ensure infections were monitored for trends. This had the potential to affect all 75 residents residing in the facility.

Inspectors wroteBased on review of the infection control log, medical record review, interview, and policy review the facility failed to ensure antibiotics were monitored and failed to ensure antibiotics met criteria for administration. This affected one resident (#184) of five residents reviewed for infections and had the potential to affect all 75 residents residing in the building.

Inspectors wroteBased on record review, staff interview, resident interview, policy review, and review of a facility investigation, the facility failed to ensure residents were free from misappropriation of medications. This affected four residents (#40, #78, #184 and #187) of four residents reviewed for misappropriation of narcotic pain medications. The facility census was 75.

Inspectors wroteBased on record review, staff interview, resident interview, policy review, and review of a facility investigation, the facility failed to thoroughly investigate allegations of misappropriation of medications. This affected six residents (#187, #78, #184, #40, #6, and #26) of six residents reviewed for misappropriation of narcotic pain medications or secured antianxiety medications and had the potential to affect two additional residents (#6 and #26) identified with orders and administration of controlled substances. The facility census was 75.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the physician was notified when a resident's blood sugar level was above the parameters in which the physician wanted notified. They also failed to ensure the physician was notified of another resident's weight gain of more than three pounds in a day and/ or more than five pounds in a week who was having daily weights obtained for monitoring of congestive heart failure (CHF). This affected one resident (#5) of five residents reviewed for unnecessary medications and one resident (#28) of one residents reviewed for edema.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident was included in their quarterly care conference to help develop an individualized plan of care for the resident as they desired. This affected one resident (#11) of one residents reviewed for care planning conferences.

Inspectors wroteBased on medical record review, observation, interview, and policy review the facility failed to ensure residents dependent on staff for personal care received nail care timely. This affected two residents ( #61 and #73) of four reviewed for activity of daily living (ADL).

Inspectors wroteBased on observations, record review, staff interview, and resident interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing and prevent new ulcers from developing. This affected one resident (#66) of three residents reviewed for pressure ulcers. The facility census was 75.

Inspectors wroteBased on record review, resident interviews, staff interviews, and review of written staff statements from facility investigation, the facility failed to timely address pain. This affected three residents (#36, #78, #185) of three residents reviewed pain. The facility census was 75.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to ensure a resident received the appropriate treatment and services for depression. This affected one resident (#78) of two residents reviewed for behavioral care in a sample of 24. The facility census was 75.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure pharmacy recommendations were responded to timely by the physician and/ or the physician provided a rationale as to why the pharmacy recommendations were not acted upon. This affected two residents (#5 and #36) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure antihypertensive medications used in the treatment for hypertension were held as needed in accordance with the physician's orders. This affected one resident (#5) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident did not receive an anxiolytic medication on an as needed (prn) basis longer than 14 days, without the physician providing the necessary documentation required for an extended use. This affected one resident (#28) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, record review, staff interview, and resident interview, the facility failed to ensure medical records were accurately documented for a resident with a pressure ulcer. This affected one resident (#66) of three residents reviewed for pressure ulcers. The facility census was 75.

Inspectors wroteBased on staff interview, policy review, review of employee personnel files, and review of facility investigation reports, the facility failed to implement their abuse/misappropriation policy related to screening by failing to attempt to obtain information from current or previous employers regarding work history prior to hiring employees to provide services in the facility. This had the potential to affect all 75 of 75 residents residing in the facility.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to initiate fall interventions and complete fall interventions as recommended. This affected three of three residents (Resident #69, #139 and #141) reviewed for falls. The facility census was 77.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to provide adequate accommodations to prevent possible resident exposure to a known pet allergy. This had the potential to affect one (Resident #69) of one resident identified as having a pet allergy. The facility census was 77.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure comprehensive assessments were accurate for immunizations. This affected two (Resident #69 and #101) of five residents reviewed for immunizations. The facility census was 77.

Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure as needed (PRN) antipsychotic medications were not administered as a fall intervention. This affected one (Resident #141) of three residents reviewed for accidents. The facility census was 77.

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food in a sanitary manner. This had the potential to affect all 77 residents who ate food from the kitchen.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to administer immunizations as required. This affected two (Resident #69 and #101) of five residents reviewed for immunizations. The facility census was 77.

Inspectors wrote3. A review of Resident #58's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia with agitation, unspecified psychosis, major depressive disorder, restlessness and agitation, peripheral vascular disease, and osteoarthritis. A review of Resident #58's care plan, dated 12/28/21 revealed she had a care plan in place for being at risk for an alteration to skin integrity related to bladder incontinence, impaired cognition, and poor safety awareness. The goal was for her to have no new areas of skin breakdown. The interventions included skin inspections, preventative treatments as ordered, keep bony prominences from direct contact, encouraging/ assisting her with turning and repositioning with routine nursing rounds and as needed (PRN) for comfort as tolerated or as she would allow. [...]

Inspectors wroteBased on observations, medical record review, staff interview, and policy review, the facility failed to ensure Resident #3, who had limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion. Actual harm occurred on 06/13/22 when Licensed Practical Nurse (LPN) #196 identified Resident #3's left dominant hand had a decline in range of motion, the hand was more contracted and the nurse was unable to use an existing carrot splint as it caused the resident increased pain. The splint was subsequently discontinued. Prior to the decline there was no evidence staff were routinely providing passive range of motion for the resident. [...]

Inspectors wroteBased on record review, review of fall investigations, interview, and policy review, the facility failed to ensure Resident #48 was properly positioned in bed when unattended resulting in an avoidable fall with major injury (hip fracture). Actual Harm occurred on 04/04/23 following a fall at 10:40 P.M. when the facility failed to ensure the resident was properly positioned in bed and left unattended resulting in the resident rolling out of bed and sustaining a hip fracture. This affected one resident (#48) of two residents reviewed for accidents.

Inspectors wroteBased on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident had the right to choose schedules and make choices about showering/ bathing. This affected one of three residents reviewed for choices (#4). The facility census was 75.

Inspectors wroteBased on closed medical record review, interview, and policy review the facility failed to ensure transfer information was documented in the resident's medical record. This affected one resident (#75) of one reviewed for hospitalization.

Inspectors wroteBased on closed medical record review, interview, and policy review the facility failed to ensure residents and/or resident representatives were provided with transfer notice as required for a facility initiated transfer. This affected one resident (#75) of one reviewed for hospitalization.

Inspectors wroteBased on record review, review of the facility's shower schedules, observation, resident interview, staff interview and policy review, the facility failed to ensure residents who were dependent on staff for personal care received the assistance they needed with washing their hair and trimming their fingernails. This affected two residents (#4 and #129) of two residents reviewed for activities of daily living.

Inspectors wroteBased on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure residents received audiology/optometry services timely when needed. This affected two residents (#12 and #50) of two residents reviewed for vision/ hearing.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a resident with significant weight loss received timely interventions as recommended by the dietetic technician. This affected one of five residents reviewed for nutrition (#31). The facility census was 75.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure residents received timely dental services. This affected one resident (#50) of two reviewed for dental.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to implement the antibiotic stewardship policy and procedure for antibiotic use. This affected two of five residents reviewed for unnecessary medications (#18 and #30). The facility census was 75.

Inspectors wroteBased on review of immunization records, policy review, and staff interview, the facility failed to ensure a resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations for a resident who refused both. This affected one of one residents who refused the influenza and pneumococcal immunizations in a sample of five (#18). The facility census was 75.

Inspectors wroteBased on review of immunization records, personnel records, staff interview, and policy review, the facility failed to ensure residents and staff were provided with education regarding the benefits and potential risks associated with the COVID-19 vaccine and failed to have policies/procedures in place regarding COVID-19 vaccines for residents. This affected one of five sampled residents (#18) and one of one staff reviewed. The facility census was 75.

Inspectors wroteBased on observation and staff interview the facility failed to ensure residents were treated with dignity by providing residents with knives at mealtime. This affected 14 of 14 residents (Residents #1, #3, #6, #21, #22, #23, #25, #26, #29, #36, #38, #42, #48, and #74) who resided on The Haven (a dementia care unit).

Inspectors wroteBased on staff interview and medical record review, the facility failed to ensure resident plans of care addressed resident's needs in the areas of activities, skin non-pressure, dementia care, eating, and device usage. This affected six of 18 sampled residents (Resident #4, #22, #44, #46, #67, and #274) whose care plans were reviewed. The census was 74.

Inspectors wroteBased on observations, medical record review, resident interview, staff interview, and facility policy review, the facility failed to provide meaningful activities to all residents. This affected four (Residents #18, #22, #44, and #67) of six residents reviewed for activities. The census was 74. Findings Include: 1. Observations from 07/26/21 at 11:00 A.M. to 08/02/21 at 3:30 P.M. revealed no group activities or activities outside of his room were offered to Resident #18. He remained in his bed the vast majority of the time. Record review revealed Resident #18 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on medical record review, policy review and interview, the pharmacy failed to ensure controlled drug records were maintained and periodically reconciled for accuracy. This affected one (Resident #52) of two residents reviewed for controlled substances. The census was 74.

Inspectors wroteBased on observations and staff interview, the facility failed to maintain a living environment free from needing repair. This affected seven (Residents #5, #7 #19, #22, #47, #48, and #67) of 74 residents in the facility. Findings Include: 1. Observations on 07/27/21 between 10:30 A.M. and 11:00 A.M. revealed the following issues in Resident #5, Resident #7, Resident #19, and Resident #47 rooms: chunks of dry wall missing from the wall behind Resident #5 and Resident #47 door (cased by the door handle), and large black marks and chunks of dry wall missing from the back wall of Resident #7 and Resident #19 room. Interview with Maintenance Staff #108 on 08/02/21 at 4:50 P.M. confirmed the chunks of drywall missing in all four resident's rooms. He stated the facility uses an electronic maintenance system to report and confirm work completed. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure residents had comprehensive assessments in the areas of activities, potential restraint use, and residing on a dementia unit. This affected two of 18 residents (Resident #22 and #67) reviewed for comprehensive assessments.

Inspectors wroteBased on resident interview, staff interview, medical record review, and observation the facility failed to maintain a resident's ability to eat. This affected one of five sampled residents (Resident #46) reviewed for nutrition.

Inspectors wroteBased on observation, staff interview, and medical record review the facility failed to ensure a resident receiving medications with blood thinning properties had a means in place to prevent bruising. This affected one of six residents (Resident #22) reviewed for unnecessary medication.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure proper supervision was provided to a resident that was a high fall risk. This affected one (Resident #28) of two residents reviewed for accidents. The census was 74. Findings Include: Record review revealed Resident #28 was admitted to the facility on [DATE]. Her diagnoses were hemiplegia and hemiparesis, neuromuscular dysfunction of the bladder, atrial fibrillation, dysarthria, dysphagia, chronic kidney disease (stage III), morbid obesity, major depressive disorder, type II diabetes, chronic obstructive pulmonary disease. Her Brief Interview for Mental Status (BIMS) score was 15, which indicated she was cognitively intact. The assessment was completed on 05/25/21. Review of Resident #28's medical records revealed on 06/23/21, staff heard her yelling from her bathroom. [...]

Inspectors wroteBased on observations, medical record review, resident interview, staff interview, and facility policy review, the facility failed to implement nutritional recommendations/interventions for residents who lost a significant amount of weight. Also, the facility failed to monitor significant weight loss and then did not provide meals as indicated on the menu to a resident. This affected three of five residents reviewed for nutrition (Residents #18, #46, #274). The census was 74. Findings Include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, staff interview, medical record review, activity calendar review, and memory brochure the facility failed to ensure residents who were diagnosed with dementia received memory care to support the resident's well-being. This affected two of three sampled residents (Resident #22 and #67) reviewed for dementia care.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure an identified drug irregularity was addressed by the physician that included the rational for rejecting the recommendation. This affected one of six sampled residents (Resident #67) reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide adequate justification for the use of anti-psychotic medications. This affected two (Residents #10 and #67) of six residents reviewed for unnecessary medications. The census was 74. Findings Include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE]. His diagnoses were Alzheimer's disease, melanoma in right ear, anxiety disorder, dementia with behavioral disturbances, vascular dementia with behavioral disturbances, major depressive disorder, and hemiplegia and hemiparesis. His Brief Interview for Mental Status (BIMS) score was four, which indicated he had a severe cognitive impairment. The assessment was completed on 04/20/21. [...]

Inspectors wroteBased on observation, medical record review, medication administration guidance review, policy review, and interview, the facility failed to ensure a medication error rate was not 5% or greater. There were 32 opportunities for error with three actual errors resulting in a 9.38 % medication error rate. This affected three (Resident #15, #30 and #59) of five residents observed during medication administration. The census was 74.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure documentation in a resident's record was accurate. This affected one of 18 sampled residents (Resident #22).

Inspectors wroteBased on staff interview, hospice contract review, and medical record review the facility failed to maintain hospice communication in the resident's medical record. This affected one of one sampled resident's (Resident #67) reviewed for hospice.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to follow acceptable infection control practices during a dressing change. This affected one (Resident #47) of one resident observed for a dressing change. The facility census was 74.