Harmony Health and Rehabilitation

Inspectors wroteBased on staff interviews, resident interviews, and record review, the facility failed to ensure residents were protected from resident to resident abuse for two of six sampled residents (R4 and R5). Specifically, resident R5 entered R4's bed, and R4 exposed his male genitalia to R5. This deficient practice placed R4 and R5 at risk for unwanted sexual contact and compromised the resident's right to be free from resident to resident abuse.

Inspectors wroteBased on staff interviews, resident interviews, and record review, the facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency (SSA) within the required time frame for two of six sampled residents. The facility's failure to report the allegation timely had the potential to delay the identification and the prevention of abuse involving other residents.

Inspectors wroteBased on staff interviews and record review, the facility failed to provide Form CMS 10055, Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), in a timely manner to two of three sampled residents(R) (R13 and R73) reviewed for liability notices. This failure prevented the residents or their responsible parties from having the ability to make an informed decision regarding the cost of continued therapy services.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Bed Hold Notice Upon Transfer the facility failed to notify the ombudsman and to provide a resident and their representative with the required written transfer and bed-hold notices following an emergency hospital transfer for one of two sampled residents (R) (R87). This failure limited the residents' and representative's ability to understand appeal rights and access ombudsman information, placing them at risk for potential denial of readmission.

Inspectors wroteBased on record review, and staff interviews, the facility failed to complete a baseline care plan for two of 27 sampled residents (R) (R85 and R29). This failure had the potential to result in the residents' medical, nursing, mental, and psychosocial needs not being met, increasing the risk for adverse outcomes.1. Review of R85's Electronic Medical Record (EMR) located under the Minimum Data Set (MDS) tab revealed a revealed an admission date of 10/31/2025. Review of the EMR located under the Evaluation tab revealed no documentation that R85's base line care plan had been completed. Interview on 03/03/2026 at 4:05 PM the MDS Coordinator (MDSC) stated that it is the nurse's responsibility to complete the base line care plan at the time of admission. The MDSC also stated that it does not look like the baseline care plan for R85 was completed. [...]

Inspectors wroteBased on record review, observations, staff interviews, and review of the facility's policy titled Hemodialysis, the facility failed to ensure safe and coordinated dialysis care for one of one sampled resident(R)(R87). Specifically, the facility did not complete required pre and post dialysis assessments, did not maintain effective communication with the contracted dialysis provider, and did not have a formal written contract or agreement with the dialysis agency responsible for providing services to the resident. These failures placed the R87 at risk for compromised health, safety, and continuity of care.

Inspectors wroteBased on observation, interviews, record review and review of the facility's policy titled Comprehensive Care Plans, the facility failed to follow the care plan interventions related to falls for one of four Residents (R) (R1) Actual harm occurred on 10/2/2025 when R1 who required two person assist with Activities of Daily Living (ADL) care rolled out of bed onto the floor during incontinent care that was being provided by one Certified Nursing Assistant (CNA). As a result of the fall, R1 sustained a distal fracture of left femur and a fracture of the lower end of the right tibia

Inspectors wroteBased on observations, interviews, record review and review of the facility's policy titled Incident and Accidents, the facility failed to provide adequate supervision to prevent accidents for one of four residents (R) (R1) reviewed for falls. Actual harm occurred on 10/2/2025 when R1 who required two person assist with Activities of Daily Living (ADL) care rolled out of bed onto the floor during incontinent care that was being provided by one Certified Nursing Assistant (CNA). As a result of the fall, R1 sustained a distal fracture of left femur and a fracture of the lower end of the right tibia.

Inspectors wroteBased on record review, staff interview, and review of the facility's policy titled Documentation of Wound Treatments, the facility failed to ensure the medical record documentation was completed and/or accurate for three of three residents (R) (R1, R3 and R4) reviewed for pressure ulcers from a total sample of nine residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Cleaning Instructions: Ice Machine and Equipment, the facility failed to ensure the ice machine was maintained in a clean and sanitary condition and failed to ensure staff wore appropriate head covering in the food service area. This deficient practice had the potential to affect 82 of the 85 residents receiving an oral diet.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Annual Inservice Education for Long Term Care 2024, the facility failed to establish, implement, and sustain a comprehensive training program for all staff that would include education on standards, policies, and procedures for infection prevention. This deficient practice had a potential to increase the risk of healthcare-associated infections and compromise the quality of care provided to the residents of the facility.

Inspectors wroteBased on observations, interviews, and review of the facility's policy titled, Resident Rights and Dignity Management, the facility failed to ensure one of 13 residents (R) (R17) was able to exercise their right to smoke.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policies titled, Resident Assessment Instrument (RAI)/Care Planning Management, and Process for Completing the MDS, CAAs and Care plans, the facility failed to ensure that the care plan was followed for three of 15 residents (R) (R24, R7, and R54). Specifically, the facility failed to ensure the care plan was followed for R24 for receiving oxygen therapy, for R7 related to positioning of an indwelling catheter, and for R54 for behaviors related to oxygen use. This deficient practice had the potential for R24, R7, and R54 to not have the care provided to them according to their individual care needs.

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to properly administer respiratory inhalant medications for one of 15 residents (R) (R24) receiving inhaled respiratory medication. Specifically, the facility failed to ensure that the Licensed Practical Nurse (LPN) properly administered inhaled medications by having the resident rinse their mouth after receiving inhaled respiratory medication.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Respiratory System Management, the facility failed to ensure that one of 15 residents (R) (R24) receiving oxygen (O2) therapy was administered the therapy in accordance with the physician's orders. This deficient practice had the potential to put R24 at risk for medical complications.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Hand Hygiene, Indwelling Catheters, Two-Tier Transmission Based Precautions, and Infection Control Manual, the facility failed to ensure infection control practices were followed for two of seven Residents (R) (R435 and R7). Specifically, the facility failed to ensure hand hygiene was performed during medication administration, failed to ensure residents with an indwelling catheter drainage bag was secured properly, and failed to ensure that the infection control policy and procedures were reviewed annually.

Inspectors wroteBased on staff interviews, record review, and review of the facility's Standard and Task List titled, Elopement Management, the facility failed to ensure that the physician and responsible party were notified of an elopement of one resident (R) (R1) from a total sample of 24 residents. This deficient practice had the potential to place R1 at risk of unmet needs and a diminished quality of life.

Inspectors wroteBased on staff interviews, record review, and review of the facility's Elopement Standard and Task List titled, Elopement Management, the facility failed to ensure the care plan was revised for one of 24 sampled residents (R) (R1). Specifically, the facility failed to revise and update R1's care plan following an elopement on 10/17/2024. This deficient practice had the potential to place R1 at risk of not receiving treatment and/or care according to their needs.

Inspectors wroteBased on staff interviews, record review, and review of the facility's Elopement Standard and Task List titled, Elopement Management, the facility failed to ensure one of 24 sampled residents (R) (R1) was adequately supervised to prevent elopement. In addition, the facility failed to ensure a door leading to the outside was secured to prevent elopement by residents. This deficient practice had the potential to place R1 at risk of avoidable injury and a diminished quality of life.

Inspectors wroteBased on resident and staff interviews, record review, review of the facility's resident admission agreement in the admission packet, and review of the facility's policy titled, Advance Directives, the facility failed to ensure one of three residents (R) (R49) wishes were correctly entered into orders to reflect the residents preferred code status and failed to ensure a copy of the resident's advance directives were obtained and filed in the medical record.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy titled, Care Plan Development, the facility failed to implement a care plan for one resident (R) R70 who had a diagnosis of post-traumatic stress syndrome and failed to follow the care plan for one resident R49. The sample size was 33 residents.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Care of Fingernail/Toenails, the facility failed to ensure that residents received toenail care timely for two of 33 sampled residents (R) (R65) and (R1). This failure had the potential to affect one resident's bilateral foot health.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility's policy titled Restorative Programs the facility failed to follow an Occupational Therapy (OT) restorative referral recommendation for passive range of motion (PROM) and orthotic application for one of one resident (R) (#49) reviewed for PROM and splint application to resident's left hand. The facility also failed to obtain a physician's order defining the specific restorative program and frequency. The deficient practice had the potential to reduce residents ability to improve independence and/or result in the progression of contractures. The sample size was 33 residents.

Inspectors wroteBased on resident interviews, staff interviews, record review, and review of the facility policy titled, Medication Administration Guidelines, the facility failed to ensure one of five residents (R) 29, reviewed for unnecessary medications received medications as ordered by the physician. Specifically, the facility failed to transcribe a medication as ordered by the provider.