Harmony Hills Healthcare and Rehabilitation Center

Inspectors wroteBased on review of facility provided documents, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of a resident utilizing a Lumbar Sacral orthosis brace (LSO-brace that supports the spine) for one of two residents (discharged Resident R1).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to obtain a complete physician order for a Lumbar Sacral orthosis brace (LSO-brace supports the spine) for one of two residents (discharged Resident R1).

Inspectors wroteBased on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were accounted for accurately for nine of twelve residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, and R9).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain sanitary conditions and practice proper infection control which created the potential for cross contamination and food borne illness (Main Kitchen) the facility failed to properly monitor refrigerator temperatures on one of two nursing units (C & D Hall unit) and failed to properly monitor residents in room personal refrigerator temperatures for three of three residents (Resident R20, R23, R50) which created the potential for food borne illness. Review of facility policy Environment dated 1/13/25 indicates all food preparation areas, and dining areas will be maintained in a clean and sanitary condition. [...]

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for three of five residents (Resident R2, R31, and R43).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of six residents sampled with hospital transfers (Residents R3, R6, and R43) and failed to obtain a physician order for discharge to home for one of six residents (Resident R56).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined the facility failed to conduct a significant change assessment for one of two residents reviewed (Resident R37).

Inspectors wroteBased on review of facility policy, record review, resident and staff interviews, and observations it was determined that the facility failed to provide a resident environment free of potential accidental hazards for one of three residents (Resident R21).

Inspectors wroteBased on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R19).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility for one of three residents (Resident R2).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in one of three medications carts (C and D Hall Medication Cart) and failed to store drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (C and D Hall Medication Room). [...]

Inspectors wroteBased on facility policy, observation, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of four residents ordered an NPO (nothing by mouth) diet (Resident R6).

Inspectors wroteBased on observations, resident and staff interviews it was determined that the facility failed to provide residents food products based on their preferences for one out of five residents (Resident R57). During an interview on 7/15/25, at 11:30 am Resident R57 voiced a concern that she is a vegetarian, doesn't drink milk. She feels her dietary needs are not being met. Review of the admission record indicated Resident R57 was admitted to the facility on [DATE]. Review of Resident R57's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/4/25, indicated the diagnoses of fracture of right femur, falls and neuropathy (damage or disease affecting nerves, typically in the peripheral nervous system, which lies outside the brain and spinal cord). [...]

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of two residents (Resident R37).

Inspectors wroteBased on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of three quarterly meetings (Quarter One of 2025). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Committee Charter policy dated 1/13/25, indicated the purpose of QAPI is to utilize a method of proactive, data-driven systematic and comprehensive process to monitor performance that identifies trends and opportunities for improvement. Review of Quality assurance and Performance Improvement sign in sheets and attendance records for Quarter One of 2025, failed to reveal the Medical Director was in attendance. During an interview on 7/17/25, at 9:54 a.m. [...]

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R2).

Inspectors wroteBased on a review of policy, observations, and staff interviews, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition and failed to properly label, date, and store food products in the kitchen refrigerator and basement freezer creating the potential for unsafe conditions and the potential for cross contamination in the main kitchen, basement freezer storage area and in one of two kitchenettes (C and D level kitchenette).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for six of 10 residents (Residents R5, R17, R28, R35, R44, and R47).

Inspectors wroteBased on review of facility policies, observations, and staff interviews it was determined that the facility failed to properly store medical supplies and biologicals in one of three medication carts (first floor B hall medication cart), one of two medication rooms (first floor medication room) and properly secure stock medications in the central supply area.

Inspectors wroteBased on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) for three of ten residents (Resident R17, Resident R25, and Resident R29).

Inspectors wroteBased on clinical record review, facility policy, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents with facility-initiated transfers (Residents R21 and R28).

Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of three residents (Resident R31).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of three residents (Resident R23) to accurately reflect the current status of the resident and care needs.

Inspectors wroteBased on review of facility policy, clinical closed record review, and staff interviews, it was determined that the facility failed to ensure a resident had a physician discharge order to return home for one of three residents (Closed Record (CR) Resident R53) and failed to ensure a resident had a physician order for care and management of an over the bed trapeze bar for one of three residents (Resident R47).

Inspectors wroteBased on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for two of five nurse aide personnel records (Nurse aide Employee E6 and Nurse aide Employee E7).

Inspectors wroteBased on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meeting (December 2023 through February 2024). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 6/17/24, indicated that the facility shall develop, implement, and maintain an ongoing, facility-wide, date-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Review of Quality assurance and performance improvement sign in sheets and attendance records indicated the facility failed to provide evidence that the facility conducted a March 2024 QAPI meeting. During an interview on 10/18/24, at 12: [...]

Inspectors wroteBased on review of facility policy, clinical records, resident and staff interviews it was determined that the facility failed to implement pharmaceutical services to ensure availability and administration of prescribed medications for one of four sampled residents (Residents R1). This deficiency is cited as past non-compliance.

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing assessments to ensure that bed rails were used to meet residents' needs and the risks associated with bed rail usage for three of three residents (Residents R10, R12 and R23).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R3).

Inspectors wroteBased on resident and staff interview it was determined that the facility failed to have a beautician available to meet resident needs for the facility.

Inspectors wroteBased on review of facility documentation, resident and staff interview it was determined that the facility failed to offer all residents the opportunity to vote for the May and November 2023 elections.