Harmony Gardens

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators were labeled, dated, and not expired. This had the potential to affect all 61 residents who received food from the facility kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure pillows were not used in a manner to restrain residents while in bed for 1 of 1 resident (R44) reviewed for restraints.

Inspectors wroteBased on interview and document review, the facility failed to ensure a subset (i.e., discharge) Minimum Data Set (MDS) was completed and transmitted to the Centers for Medicare and Medicaid (CMS) database in a timely manner for 1 of 1 resident (R30) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, and document review the facility failed to assess residents' ability to independently empty and report urine output for 1 of 1 resident (R50) reviewed who had a urinary catheter.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess physical restraints (manual method or physical or mechanical device, material, or equipment attached or adjacent to a resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) for 4 of 4 residents (R1, R2, R3 and R4) reviewed who use bedrails.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt alternative devices before using bedrails on residents beds, assess the residents for risk of entrapment, review risks and benefits for bed rail use, ensure bed dimensions were appropriate for 4 of 4 residents (R1, R2, R3 and R4) review for bed rails.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately report allegations of abuse and injury of unknow origin to the State Agency (SA) no later than two hours after the allegation is made for 1 of 1 resident (R1) reviewed. R1's family filed a facility grievance that indicated staff was aggressive with R1 and a facility nurse found bruising that were similar to finger marks on R1's upper arm where a cause was not identified. Neither event was reported.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide evidence that a thorough investigation was completed on allegations of an injury of unknown origin for 1 of 4 residents (R1) reviewed. Staff found bruising resembling finger markings on R1's upper arm. R1's family had filed a grievance report regarding aggressive care one day prior to the bruising findings.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow transmission based precautions (TBP) based on signage located outside resident's doors for R29, R45, R17, R14. This had the potential to affect all residents. Additionally, the facility failed to ensure hand hygiene was completed during 3 of 6 residents (R14, R55, R47) observed for medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure timely care was provided in a manner to maintain and enhance quality of life for 1 of 2 residents (R64) reviewed for call lights.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were comprehensively assessed safe for self-administration of medication for 1 of 1 resident (R36) reviewed and observed for self-administration of medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure ambulation program was completed daily for 1 of 1 residents (R62) who was reviewed for ambulation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care planned interventions were implemented for 1 of 2 residents (R64) reviewed for pressure injury.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a hand splint was used for 1 of 1 resident (R30) reviewed for range of motion (ROM).

Inspectors wroteBased on observation, interview and record review the facility failed to comprehensively assess and implement interventions necessary to maintain continence for 1 of 1 residents (R27) reviewed for bowel and bladder.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure weekly weights were completed for 1 of 1 resident (R32) who was reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and monitor new bruising at the fistula site for 1 of 1 residents reviewed for dialysis.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dietary preferences were accommodated for 1 of 1 resident (R17) reviewed for food preferences.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure care planned interventions were followed during transfer for 1 of 3 residents (R1) reviewed for accidents when staff failed to use a transfer belt. This resulted in actual harm for R1 who fell during a staff assisted transfer and sustained a subarachnoid hemorrhage. The deficient practice was corrected prior to the start of the survey therefore, was issued at past noncompliance.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standard of practice when cardiopulmonary resuscitation (CPR) (compressing the chest to pump blood through the body and blowing air into a persons lungs in attempt to revive a person with no pulse who is not breathing) was initiated on a resident who displayed signs of rigor mortis (the stiffening of the joints and muscles of a body after death) for 1 of 1 resident reviewed for death. R1's minimum data set (MDS) dated [DATE], indicated R1 had died in the facility on [DATE]. [...]

Inspectors wroteBased on interview and document review, the facility failed to allow active resident and resident representative participation in the development and review of care plan for 1 of 1 resident (R59) that was a new admission.

Inspectors wroteBased on observation, interview and document review the facility failed to clean and maintain resident's wheelchairs for 1 of 1 resident (R23).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents that were prescribed psychotropic medications were monitored for target behaviors for 1 of 1 newly admitted resident (R59) reviewed for unnecessary medications.