Harmony Care at Stamford

Inspectors wroteBased on interviews and record review[KA73.1], the facility failed to maintain a quality assessment and assurance committee consisting at a minimum of the required committee members for 4 quarterly meetings reviewed for QAPI[KA74.1]. The facility did not ensure the Medical Director or a representative attended quarterly QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the assessment accurately reflected the resident's status for 4 of 5 (Resident #1, Resident #2, Resident #18, and Resident #30) reviewed for accuracy of assessments. The facility failed to ensure Resident #1, Resident #2, Resident #18, and Resident #30 had tobacco use accurately coded on the admission/annual MDS assessment. This failure could place residents at risk for inadequate care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were seen by a physician at least once every 60 days for 3 of 13 Residents (Resident #2, Resident #4, and Resident #16) whose records were reviewed for physician visits. The facility failed to ensure Resident #2's, Resident #4's, and Resident #16's primary care physician met with them as required. This failure could place residents at risk for medical needs not being addressed or met. Based on interview and record review, the facility failed to ensure the residents were seen by a physician at least once every 60 days for 3 of 13 Residents (Resident #2, Resident #4, and Resident #16) whose records were reviewed for physician visits. The facility failed to ensure Resident #2's, Resident #4's, and Resident #16's primary care physician met with them as required. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 1 of 13 residents (Resident #25) reviewed for informed decisions. The facility failed to ensure Resident #25 or their representative signed consent for psychotropic medication trazodone and sertraline prior to administering medication. This failure could place residents at risk of not being informed of their health status, which would allow them to make informed decisions regarding their care.

Inspectors wroteBased on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability or a related condition for level II resident review upon a significant change in status for 1 of 13 residents (Resident #28) reviewed for PASSR. The facility failed to follow up with the local authority for PASRR level II determination when Resident #28's PASRR level 1 dated 2.17.2024 screening reflected they were positive for Mental Illness. This failure could place residents at risk of not receiving specialized and/or habilitative services as needed to meet their needs.

Inspectors wroteBased on interviews and record reviews[KA41.1], the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #25) of 13 residents reviewed for care planning. The facility failed to develop a baseline care plan for Resident #25 within 48 hours of her admission. This failure could place residents at risk of not receiving effective, person-centered care. Record review of Resident #25's electronic face sheet dated 06/17/2026 reflected an [AGE] year-old female, admitted [DATE], with the following diagnoses of depression, anxiety, and dementia. Further review reflected resident was he own responsible party. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Residents #1 and Resident #30) reviewed for care plans. The facility failed to ensure Resident #1 had a care plan in place for smoking. The facility failed to ensure Resident #30 had a care plan in place for smoking. This failure could place residents at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who on interview, and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 13 residents (Resident #4) reviewed for medical records. The facility failed to obtain physician orders with setting and parameters for use of CPAP for Resident #4. This failure could place residents at risk for respiratory illnesses and risk for respiratory failure.

Inspectors wroteBased on interview, and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 of 13 residents (Resident #28 and Resident #30) reviewed for medical records. The facility failed to ensure Resident #28, and Resident #30 had safe smoking assessments completed. This failure could place residents at risk of health and safety due to no updated safe smoking assessments.

Inspectors wroteBased on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 7 (Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #10, Resident #16) of 12 residents reviewed for MDS assessments. The facility failed to complete Resident #3's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #4's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #5's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #7's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #8's Quarterly MDS Assessment within 14 calendar days of the ARD. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #11, Resident #70) of 14 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for hospice services for Resident #11. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for Oxygen use for Resident #70. This failure could place the residents at risk for decreased quality of life and not having their needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 (Resident #2 Resident #70) of 3 residents reviewed for respiratory care. 1. The facility failed to obtain a Physician's order for Resident #2's continuous supplemental oxygen. 2. The facility failed to obtain a Physician's order for Resident #70's continuous supplemental oxygen. 3. The facility failed to post oxygen in use sign for Resident #70. These failures could place residents at risk of not receiving the necessary respiratory care to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days and to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #10, Resident #127, and Resident #147) of 12 residents reviewed for unnecessary medications. The facility failed to ensure Resident #10's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #127's PRN Alprazolam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 2 (Resident #15 and Resident #174) of 12 residents reviewed for medications. The facility failed to hold Carvedilol (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 15 doses in April 2025 for Resident #15. The facility failed to hold Lisinopril (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 5 doses in April 2025 for Resident #15. The facility failed to hold Midodrine (medication to increase blood pressure) per parameters stated in physicians' orders for a total of 19 doses in April 2025 for Resident #15. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 1 (Resident #2) of 12 residents reviewed for baseline care plans. The facility failed to ensure that Resident #2 had baseline care plan developed within 48 hours after being admitted to the facility on [DATE]. These failures placed the residents at risk of not having continuity of care to safeguard against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 1 facility reviewed for environmental concerns. The facility failed to repair damaged walls in hot water closets located outside2, 3, 4, and 5 halls has damaged drywall with holes at the bottom and signs of rodent droppings. This deficient practice could place resident, staff, and the public at risk of an unsafe and unsanitary environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a resident environment that was free of pests and rodents for 1 of 1 facility reviewed for effective pest control in that: The facility failed to maintain an affective pest control program. This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment in 1 of 3 halls (Hall 1) observed for environmental conditions for Resident #1 and #2, in that: 1. The facility failed to prevent the temperature from being 86°F in Resident #1's room. 2. The facility failed to prevent the temperature from being 86°F in Resident #2's room The facility's failure placed the residents at risk for harm by a diminished quality of life and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 FY quarters reviewed (FY Quarter 1 2024 (October1-December 31) reviewed for administration. The facility failed to submit data to CMS for FY Quarter 1 2024 (October1-December 31). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 5 (Resident #1, Resident #4, Resident #8, Resident #14, and Resident #24) of 5 residents reviewed for care plans. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified for Resident #1, Resident #4, Resident #8, Resident #14, and Resident #24. This failure could place residents at risk for not receiving care and services individualized to meet their specific physical, mental, and/or emotional needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise resident-centered comprehensive care plans within 7 days of a comprehensive assessment for 4 (Resident #1, Resident #4, Resident #8, and Resident #14) of 5 residents reviewed for care plans. The facility failed to review and revise Resident #1, Resident #4, Resident #8, and Resident #14's, Comprehensive Patient-Centered Care Plan within 7 days following the completion of a comprehensive assessment. The facility failed to review and revise Resident #8's Comprehensive Patient-Centered Care Plan to reflect a change in condition regarding the bed and chair alarms no longer necessary for the resident's safety. These failures could put residents at risk for not receiving the care and services needed to maintain or improve physical, mental, emotional, psychological well-being.

Inspectors wroteBased on interview and record review, the facility failed to investigate an injury of unknown origin and report to HHSC for 1 out of 2 residents (Resident #1) reviewed for injury of unknown origin. The facility failed to report an injury of unknown origin, swelling and bruising around Resident #1's right eye, to HHSC. This failure could place residents at risk of abuse, fear, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to investigate an injury of unknown origin and report to HHSC for 1 out of 2 residents (Resident #1) reviewed for injury of unknown origin. The facility failed to complete an investigation of swelling and bruising around Resident #1's right eye first observed on 10/28/23. This failure could place residents at risk of abuse, fear, and a diminished quality of life.