Harmony Court Rehab and Nursing

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to provide a safe, functional and sanitary environment. This affected one (Residents #78) and had the potential to affect all of the residents in rooms 302, 304, 317, and 325. The facility census was 96 residents.

Inspectors wrote:THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, staff interview, review of facility Self-Reported Incidents (SRI), review of the facility investigation, review of the local weather report, and review of the facility policy, the facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from the facility. This resulted in Immediate Jeopardy when Resident #70 left the facility without staff knowledge, was missing approximately three hours and was found approximately 0.8 miles from the facility by a facility staff member before returning to the facility. This affected one (Resident #70) of three residents reviewed for risk of elopement. The facility identified 26 residents at risk for elopement. The facility census was 101. On 04/02/26 at 1:05 P. [...]

Inspectors wroteBased on medical record review, observation, staff interview, review of pharmacy guidelines, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected five Residents (#26, #55, #85, #86 and #99) of the 24 residents with medications stored in the unit-100 medication cart. The facility census was 101 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and resident interview, the facility failed to provide residents with a dignified dining experience. This affected three (Residents #21, #51 and #54) but had the potential to all affect the 99 facility-identified residents who received meals from the kitchen. The facility census was 101 residents.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure call lights were kept within resident reach. This affected one (Resident #94) of three residents reviewed for call lights. The facility census was 101 residents.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed ensure resident rooms were clean and sanitary. This affected one (Resident #94) of three residents reviewed for physical environment. The facility census was 101 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide nail care for dependent residents. This affected two (Residents #21 and #82) of three residents reviewed for activities of daily living (ADL) care. The facility census was 101 residents.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure staff practiced proper hand hygiene while delivering meal trays to residents. This affected three (Residents #21, #51, #54) and had the potential to affect the 99 facility-identified residents who received meals prepared in the facility kitchen. The facility census was 101 residents.

Inspectors wroteBased on medical record review, staff interview, review of Self-Report Incidents (SRI) and facility policy review, the facility failed to implement their abuse policy when an allegation of sexual abuse was reported. This affected two Residents (#01 and #12) out of the three residents reviewed for abuse. The facility census was 106. 1) Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. Diagnoses included abscess of right foot, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability (ID), essential primary hypotension, and diabetes mellitus (DM). The resident was housed in the secured Memory Care Unit (MCU) and had a guardian related to mental disability. [...]

Inspectors wroteBased on medical record review, staff interview, review of Self-Report Incidents (SRI) and facility policy review, the facility failed to report an allegation of sexual abuse. This affected two Residents (#01 and #12) out of the three residents reviewed for abuse. The facility census was 106. 1) Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. Diagnoses included abscess of right foot, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability (ID), essential primary hypotension, and diabetes mellitus (DM). The resident was housed in the secured Memory Care Unit (MCU) and had a guardian related to mental disability. [...]

Inspectors wroteBased on medical record review, interview, and facility policy review. The facility failed to investigate an allegation of abuse. This affected two Residents (#01, #12) out of three residents (#01, #03, #12) reviewed. The facility census was 106. 1) Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. Diagnoses included abscess of right foot, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability (ID), essential primary hypotension, and diabetes mellitus (DM). The resident was housed in the secured Memory Care Unit (MCU) and had a guardian related to mental disability. Review of physician orders for Resident #01 dated 08/16/23, revealed resident was ordered to be housed in the secured unit for safety of self and others related to major depressive disorder. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure physician visits were signed and dated in a timely manner. This affected two Residents (#01, #12) out of two residents reviewed. The facility census was 106. 1) Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. Diagnoses included abscess of right foot, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability (ID), essential primary hypotension, and diabetes mellitus (DM). The resident was housed in the secured Memory Care Unit (MCU) and had a guardian related to mental disability. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #01 was cognitively intact. The resident was independent or required minimal assistance with activities of daily living (ADL). [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure medications were given as prescribed. This affected one (#15) of four residents reviewed for medication administration. The facility census was 107.

Inspectors wroteBased on medical record reviews, observations and staff interviews the facility failed to ensure medications were administered as ordered resulting in three medication errors out of 27 opportunities observed which resulted in an 11.11 percent (%) error rate. This affected one (#15) of four residents reviewed for medication administration. The facility census was 107.

Inspectors wroteBased on observation, staff interview, and review the facility policy, the facility failed to ensure proper storage of medication. This had the ability to affect all 25 residents on the hall. The facility census was 107.

Inspectors wroteBased on observation, staff interviews and Centers for Disease Control and Prevention guidelines the facility failed to ensure proper infection control measures were followed during medication administration. This had the potential to affect one Resident (#14) of four reviewed. The facility census was 107.

Inspectors wroteBased on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to ensure residents were free from verbal abuse by the staff. This affected one (Resident #104) of three residents reviewed for abuse. The facility census was 112 residents.

Inspectors wroteBased on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to prevent resident elopements. This affected one (Resident #45) of three residents reviewed for elopements. The facility census was 112 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) prior to provision of care for residents on enhanced barrier precautions (EBP.) This affected two (Residents #11 and #13) of three residents reviewed. The facility census was 107 residents.

Inspectors wroteBased on review of facility Self-Reported Incident Reviews (SRIs), staff interview, and review of the facility policy, the facility failed to ensure allegations of misappropriation were reported in a timely manner to the Ohio Department of Health (ODH). This affected one (Residents #12) of 12 residents reviewed for misappropriation. The facility census was 110 residents.

Inspectors wroteBased on review of Self-Reported Incident Reviews (SRIs) staff interview, and review of the facility policy, the facility failed to conduct a thorough investigation of misappropriation of resident medications and failed to protect residents during the investigation. This affected one (Residents #12) of 12 residents reviewed for misappropriation and had the potential to affect all of the residents residing in the facility. The facility census was 110 residents.

Inspectors wroteBased on medical record review, observation, and staff interview the facility failed to ensure residents' toilets were functioning properly. This affected two (Residents #58 and #63) of two residents reviewed for physical environment. The facility census was 102 residents.

Inspectors wroteBased on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the water temperature in residents' rooms was within safe temperature limits to prevent possible scalding injuries. This affected two (Residents #35 and #38) of two residents reviewed for physical environment. The facility census was 102 residents.

Inspectors wroteBased on medical record review, staff interview, review of hospital records, review of hospice notes, review of a transportation report, observations, and review of facility policy, the facility failed to ensure one resident (Resident #87) did not experience neglect. This resulted in Immediate Jeopardy and the potential for serious harm, injury, and/or negative health outcomes when on 12/03/23 Resident #87, whose left hand was discolored and painful, did not receive an x-ray as ordered, was not medicated for pain, and was not assessed by a physician or appropriately assessed by a nurse. She was not seen by a physician, and the primary care physician was not made aware of her condition. There was no documentation that Resident #87's radial pulse or capillary refill was assessed for appropriate blood flow to her left hand. X-rays were ordered on 12/03/23 but not completed until 12/07/23. [...]

Inspectors wroteBased on observation, review of a food menu, review of a food substitution log, staff interview, and policy review, the facility failed to ensure approved menus were followed. This affected all residents except seven (#43, #75, #77, #96, #353, #354, and #359) residents that received no food by mouth. The facility census was 108.

Inspectors wroteBased on observation, staff interview, review of a facility provided list of residents by diet type, and policy review, the facility failed to ensure the kitchen and equipment were clean and sanitary, and resident food and drink items were stored in a manner to prevent spoilage. This affected all resident with the exception of seven (#43, #75, #77, #96, #353, #354, and #359) residents identified by the facility that received no food by mouth. The facility census was 108.

Inspectors wroteBased on observation, medical record review, staff interview, review of water management logs, review of infection control logs, review of staff personnel files, review of a water management plan, and review of facility policies, the facility failed to ensure newly hired employees and residents admitted to the facility were timely screened for tuberculosis, failed to ensure resident personal use items were clean and sanitary, failed to ensure testing measures were maintained to prevent bacteria growth in the water system, failed to adequately track resident infections, and failed to maintain proper infection control measures when performing resident care. [...]

Inspectors wroteReview of record review, staff interviews, and facility policy reviews, the facility failed to implement the antibiotic stewardship program routinely to ensure infections and antibiotics were monitored. This had the potential to affect all 108 residents in the facility.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure residents were not served meals in disposable Styrofoam food boxes. This affected 11 (Residents #12, #18, #20, #32, #47, #54, #76, #84, #89, #93 and #303) of 11 observed for meal services. Additionally, the facility failed to ensure a resident's urinary catheter bag was covered for dignity. This affected one (Resident #361) of one resident observed for catheter bag coverage. The facility census was 108.

Inspectors wroteBased on observation, staff interview, review of a food recipe, and review of a facility list of residents by diet type, the facility failed to ensure pureed food items were prepared following an approved recipe to conserve the nutritional value. This affected five (#19, #31, #34, #44, and #98) of five residents identified by the facility that receive pureed diets. The facility census was 108.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the kitchen hood was maintained in a safe condition. This affected all residents except seven residents (#43, #75, #77, #96, #353, #354, and #359) who received no food by mouth. The facility census was 108.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's call light was within reach and a resident's privacy curtain were in good repair. This affected two (#42 and #62) residents out of 35 residents reviewed for call lights. The facility census was 108.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's code status was accurate in the medical record. This affected one (Resident #62) of one reviewed for advanced directives. The facility census was 108.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's family member was made aware of an injury the resident incurred. The facility also failed to ensure the resident's primary care physician was consulted when the resident had a change of condition. This affected one (Resident #87) of one reviewed for notification. The facility census was 108.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents were given a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) when being cut from skilled services and remaining in the facility. This affected two (Residents #154 and #155) of three residents reviewed for beneficiary notices. The facility census was 108.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's walls were free from patches and a resident's vent and ceiling were free of debris. This affected three (Resident #16, #60, and #69) residents of three residents reviewed for environment. The facility census was 108.

Inspectors wroteBased on record review, interview, observation, and facility policy review, the facility failed to ensure a resident was free from restraints. This affected one (Resident #355) of one resident reviewed for the use of restraints. The facility census was 108.

Inspectors wroteBased on record review, interview, review of Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure an allegation of misappropriation and an allegation of injury of unknown origin were reported to the state agency. This affected two (Residents #69 and #87) of two residents reviewed for abuse. The facility census was 108.

Inspectors wroteBased on record review, interview, review of Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure an allegation of misappropriation and an allegation of injury of unknown origin were thoroughly investigated. This affected two (Residents #69 and #87) of two residents reviewed for abuse. The facility census was 108.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's dental status was accurately coded on the Minimum Data Set (MDS) assessment. This affected one (Resident #38)of one resident reviewed for accuracy of resident assessments. The facility census was 108.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's baseline care plan addressed a resident's risk for skin impairment. This affected one (Resident #62) of three residents reviewed for care planning. The facility census was 108.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure care plans reflected the resident's current status. This affected two (Residents #57 and #42) of five residents reviewed for care planning. The facility census was 108.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a comprehensive care plan was updated to reflect a resident's risk for skin impairment. This affected one (Resident #62) of three residents reviewed for care planning. The facility census was 108. Findings inlcude: Review of the medical record for Resident #62 revealed an admission date of 04/14/23. Diagnoses included hemiplegia and hemiparesis, major depressive disorder, dementia, dependence on wheelchair, and cognitive deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact. Resident #62 required extensive one-person physical assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the admission skin assessment dated [DATE] revealed Resident #62 had skin issues including a skin tear. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received routine nail care and assistance with grooming. This affected three (#38, #49 and #62) residents out of six residents reviewed for activities of daily living (ADL) care. The facility census was 108.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to reposition and check dependent residents to see if they needed incontinence care in a timely manner. This affected two (Residents #77 and #96) of two residents reviewed for repositioning. The facility census was 108.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received routine podiatry care. This affected one (Resident #38) of one resident reviewed for podiatry services. The facility census was 108.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place for two residents (#2 and #14) of two residents reviewed for falls. Facility census was 108.

Inspectors wroteBased on review of the medical record, observation, interview, and facility policy, the facility failed to provide safe positioning of a urinary Foley catheter bag. This affected one (Resident #355) of two residents reviewed for positioning of a catheter bag. The facility census was 108.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to administer supplemental tube feeding as ordered. This affected one (#43) of three residents reviewed for tube feedings. The facility census was 108.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure a resident's oxygen tubing was dated and changed timely, and failed to ensure oxygen tubing was appropriately connected to the concentrator. This affected two (#49 and #69) of two residents reviewed for oxygen therapy. The facility census was 108.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure residents were provided interventions for pain management in a timely manner. This affected one (#87) of 32 residents reviewed for pain control. The facility census was 108.

Inspectors wroteBased on personnel file review, staff interview, and policy review, the facility failed to ensure state tested nurse aides (STNAs) received performance evaluations at least every 12 months. This affected two (#03 and #24) of two STNA personnel files reviewed for performance evaluations. The facility census was 108.

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to ensure pharmacy recommendations and irregularities were addressed by the physician in a timely manner. This affected two (#09 and 57) of five residents reviewed for unnecessary medications. The facility census was 108.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure gradual dose reductions were attempted in a timely manner and failed to ensure residents had appropriate indications for use of antipsychotic medications. This affected two (#09 and #42) of five residents reviewed for unnecessary medications. The facility census was 108.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to timely administered medications as ordered resulting in a medication error rate greater than five percent (%). There were two medication errors observed out of 27 opportunities for a medication error rate of 7.4%. This affected one (#98) of five residents observed during medication administration. The census was 108.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to administer medications as ordered by the physician resulting in significant medication errors. This affected two (#42 and #98) out of five residents reviewed for medications. The facility census was 108.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and review of facility policy, the facility failed to ensure a resident received routine dental care. This affected one (#38) of two residents reviewed for dental services. The facility census was 108.

Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to ensure medications administered to residents were accurately documented in the medical record. This affected one (#87) out of 32 residents reviewed for medical record documentation. The facility census was 108.

Inspectors wroteBased on observations, record reviews, and resident and staff interviews, the facility failed to ensure resident call lights were in working order. This affected three (#38, #60, and #69) of 35 residents reviewed for call lights. The facility census was 108.

Inspectors wroteBased on record review, review of the facility policy, and staff interview, the facility failed to the facility failed to ensure a state tested nurse aide (STNA) received a minimum of 12 hours of in services or training per year. This affected one of two STNAs reviewed for STNA in services. This had the potential to affect all 108 residents residing in the facility.

Inspectors wroteBased on observation and staff interview, the facility failed to post the daily nurse staffing data. This d the potential to affected all 108 residents residing in the facility. The facility census was 108.

Inspectors wroteBased on medical record review, review of facility initiated transfer notification, and staff interview, the facility failed to provide each resident with a notice before transfer/discharge that include all information required in the contents of the notice. This affected four residents (#13, #21, #73, and #92) of five reviewed for hospitalization. The facility census was 97.

Inspectors wroteBased on medical record review, observation, shower schedule review, and staff and resident interview, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary care and services to maintain good grooming and hygiene. This affected five residents (#63, #72, #73, #83, and #95) of five reviewed for ADLs. The facility census was 97.

Inspectors wroteBased on medical record review, observation, and staff interview the facility failed to provide an ongoing activity program to meet each resident's individual needs and preference. This affected six residents ( #12, #20, #56, #63, #69, and #73) of nine residents reviewed for activities. The facility census was 97.

Inspectors wroteBased on observation, staff interview, review of water temperature monitoring log, review of plumber service report and review of facility policy and procedures, the facility failed to maintain water temperatures in resident areas at a safe and comfortable level. This had the potential to affect 11 independently mobile residents on Unit 200 (#26, #36, #42, #45, #54, #53, #55, #56, #64, #70 and #80), the secured unit for female residents with dementia, as well as six independently mobile residents located (#24, #25, #68, #90, #93, and #100) in the unsecured section of the 200 Unit (rooms number 200 included in the 300 B Unit). The facility census was 97.

Inspectors wrote3. On 02/24/20 at approximately 12:15 P.M., Resident #37 was observed walking up and down the locked 300 hall men's dementia unit. He was observed spitting out thick secretions from his mouth on his hands, lower arms, and on to the floor. Some of the secretions looked like undigested pureed food. His hands were observed by two surveyors to be glistening with sputum. The male housekeeper was off the unit at the time as he was on his lunch break. The sputum was on the floor for approximately 15 minutes until Licensed Practical Nurse (LPN) #48 brought some towels and washcloths from the other adjacent unit. When asked what she was doing with the linens, she stated it was to clean up the sputum. She was not using any disinfectant to clean up the sputum/secretions. [...]

Inspectors wroteBased on observation, staff interview, and review of maintenance request logs, the facility failed to provide a functional, sanitary, and comfortable environment for residents, staff, and the public. This had the potential to affect all 24 Residents (#9, #12, #14, #22, #26, #30, #34, #36, #42, #45, #49, #52, #53, #54, #55, #56, #63, #64, #67, #69, #70, #73, #88, and #91) who resided on Unit 200, as well as one Resident (#13) on Unit 100. The facility census was 97.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure residents were enabled and encouraged to make choices on what they preferred to eat at mealtimes. This affected one (Resident #5) of five reviewed for nutrition. The facility census was 97 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) letter 48 hours prior to being discharged from Medicare Part A Services. This affected one (Resident #202) of three sampled residents. The facility census was 97 residents.

Inspectors wroteBased on medical record review, observation, and staff and resident interview, the facility failed to implement each residents plan of care related to activity needs and preference. This affected three residents (#12, #69 and #73) of nine residents reviewed for activities. The facility census was 97.

Inspectors wroteBased on medical record review and interviews the facility failed to develop and implement a discharge plan for residents. This affected two (#95, #103) of three residents review for discharge planning. The facility census was 97.

Inspectors wroteBased on medical record review, interview and review of facility policy the facility failed to attempt gradual dose reductions (GDR) for residents receiving psychotropic medications. This affected two (#39 and #95) of six residents reviewed for unnecessary medications. The facility also failed to ensure a resident was receiving the correct dose of a psychotropic medication. This affected one (Resident #69) of six residents reviewed for unnecessary medications. The facility identified 78 residents as receiving psychotropic medications.

Inspectors wroteBased on observation, staff interview and review of facility policy the facility failed to discard expired medications and Control Solution (glucometer testing solution). This directly affected one (Resident #94) and had the potential to affect all residents of the facility. The census was 97.

Inspectors wroteBased on medical record review, staff interviews and review of facility policy the facility failed to ensure documentation of wound treatments was completed in a residents records. This affected one (Resident #12) of one reviewed for pressure ulcer treatments. The facility identified four residents with pressure ulcers. The resident census was 97.