Harmony House Health Care Center

Inspectors wroteBased on record review and interview, the facility failed to ensure residents with contractures (shortened muscles) received necessary restorative nursing care to maintain or improve functional potential. Specifically, management canceled passive range of motion (PROM), active range of motion (AROM), and walking programs for Resident #2, Resident #6, Resident #7, Resident #8, and Resident #10 without documenting a clinical rationale in the progress notes. The facility lacked trained or dedicated staff to deliver restorative care interventions. The facility reported a census of 51 residents.

Inspectors wroteBased on record review, interviews, policy review, the facility failed to ensure specialized respiratory care was safely provided by qualified personnel for 4 of 4 residents on mechanical ventilation (a life-support treatment that uses a machine to move air in and out of your lungs when you cannot breathe adequately on your own). The facility utilized floor staff to work in the respiratory therapy department and allowed a Licensed Practical Nurse (LPN) to function as the sole licensed nurse onsite without a Registered Nurse (RN) or Respiratory Therapist (RT) present in the building (Resident #1, #5, #6, and #11). The facility reported a census of 51 residents.

Inspectors wroteBased on record review, interviews, and policy review the facility failed to ensure 1 of 3 resident received necessary care and services in accordance with professional standards of practice, her comprehensive assessment, and her plan of care (Resident #1). Specifically, staff failed to administer ordered respiratory treatments by omitting or allowing the refusal of tracheostomy (breathing tube) cares on six occasions in May 2026, and failed to provide ordered nutrition by failing to administer her full tube feeding regimen on 13 separate days in May 2026. The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, family, and staff interviews, the facility failed to provide consistent showers to 1 of 3 residents reviewed (Resident #2). The facility reported a census of 51 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide sufficient nursing staff to respond to call lights in a timely manner for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 51 residents.

Inspectors wroteBased on observations, interviews, and policy review the facility failed to ensure cold food items were maintained at or below 40 degrees Fahrenheit (4 degrees Celsius) and served immediately to prevent potential bacterial growth. Specifically, a half-gallon of milk sat out at room temperature without an ice bath for at least eight minutes, reaching a temperature of 53 degrees Fahrenheit before Staff B, Certified Nurse's Aide (CNA), poured and served a glass of it to a resident. Additionally, the facility left breakfast trays exposed to the open air on a dining room half wall before serving to a resident. One resident, Resident #13 who received one of the meals reported the breakfast was cold as usual. The facility reported a census of 50 residents.

Inspectors wroteBased on observations, staff interviews and policy review the facility failed to maintain a sanitary kitchen; failed to serve and prepare food in accordance with professional standards for food safety to reduce the risk of cross contamination and food borne illness. The facility reported a census of 50 residents.

Inspectors wroteBased on observation, record review, staff interviews, the facility failed to implement standard infection control practices and Enhanced Barrier Precautions (EBP) (involves the use of gowns and gloves during high-contact resident care activities for residents known to be colonized, infected and at increased risk of Multidrug Resistant Organisms (MDRO) (bacteria that are resistant to three or more families of antibiotics) for 3 of 3 residents (Resident #15, Resident #24 and Resident #4). The facility also failed to review their infection policy yearly. The facility reported a census of 50 residents.

Inspectors wroteBased staff interview, clinical record review, and facility policy review, the facility failed to maintain a resident's nutritional status for 1 of 5 residents reviewed (Resident #4). As evidenced by a significant, unexplained weight loss from 130 pounds on 1/05/26 to 119.5 pounds on 3/25/26. The facility failed to consistently follow the Care Plan intervention to notify the physician and dietitian of significant weight change. Furthermore, the facility did not follow its own policy for Notification for Change in Condition by failing to consult with the resident's physician and notify the Dietitian of a significant change in status (weight loss) and the significant alteration of treatment (reduction of enteral feedings from five times to two times per day) without a documented physician's order or indication. [...]

Inspectors wroteBased on resident and staff interviews, clinical record review, facility Grievance Log review, call light log review and facility policy review, the facility failed to answer call lights in a timely manner to meet resident needs for 3 of 3 residents (Resident #4, #9, and #11) reviewed for call lights. The facility failed to answer residents' calls for assistance in a timely manner, with logged wait times for multiple residents frequently exceeding acceptable limits (greater than 15 minutes), sometimes lasting over an hour and a half. The failure persisted despite residents reporting concerns through interviews and the facility's own grievance logs and after staff were reportedly re-educated on the importance of responding to call lights and carrying communication devices. [...]

Inspectors wroteBased on observation, resident and staff interview, clinical record review, and facility policy review, the facility failed to communicate to Residents #3, #4, and #12 in a dignified manner and ensure communication between staff, within hearing distance of Resident #3, was conducted in a dignified manner for 3 of 4 residents (R#3, R#4, and R#12) reviewed for resident rights. The facility reported a census of 42 residents.

Inspectors wroteBased on staff interviews, clinical record review, and facility policy review, the facility failed to thoroughly investigate an allegation of abuse. The facility omitted written witness statements and documentation of additional residents' interviews from the investigation. The facility reported a census of 42 residents.

Inspectors wroteBased on observations, clinical record review, staff interview, and facility policy review the facility failed to administer medications as ordered for 3 out of 6 residents reviewed (Residents #1, #4, and #8). The facility reported a census of 42 residents.

Inspectors wroteBased on staff interview, clinical record review, facility Grievance log review, and facility policy review, the facility failed to bath residents at least once per week for 2 of 3 resident (Resident #2 and Resident #4) reviewed for resident's rights. The facility reported a census of 42 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review the facility failed identify a change in condition that required physician notification for 2 of 4 residents reviewed (Residents #3 and #5). The facility failed to provide necessary care for two residents. When Resident #5's CAT scan on 2/18/26 diagnosed a pulmonary embolism (PE). The facility delayed treatment until 2/20/26, despite a call from his Guardian and a staff assessment noting a low pulse ox. The Medical Director expected immediate provider notification. When Resident #3, had two episodes of unresponsiveness and dizziness on 2/28/26, and a dangerously low blood pressure (60/40) on 3/1/26. The facility delayed nursing documentation, assessment, and physician notification until 3/2/26. The facility reported a census of 42 residents.

Inspectors wroteBased on staff interview, clinical record review, facility grievance form review, and facility policy review, the facility failed to provide supervision of Resident #6 while outside smoking on 1/4/26. In addition the facility failed to complete smoking or elopement assessments for 1 of 6 residents (Resident #6) reviewed for inadequate staff supervision. The facility did not consistently follow its own safety procedures for Resident #6, identified as a dependent smoker with a risk of wandering. The facility failed to complete the required annual updates to the resident's smoking and elopement risk assessments after 2024. A nurse left the resident unattended outside while smoking, which violated the Care Plan requiring supervision due to the resident's inability to smoke safely. [...]

Inspectors wroteBased on observations, clinical record review, staff interview and facility policy review the facility failed to provide tube feeding care per the physician's orders for 2 out of 5 residents reviewed (Residents #1 and #10). The facility failed to ensure to administer and document medically necessary nutritional feedings, water flushes, and g-tube (a feeding tube that goes through the skin directly into the stomach) residual checks as ordered for Resident #1. Additionally, the facility failed to ensure staff followed physician's orders for the required water flush amounts before and after medication administration via tube feeding for Resident #10, providing unverified standard amounts, and lacked a clear policy to guide staff on proper tube feeding medication procedures. The facility reported a census of 42 residents.

Inspectors wroteBased on staff interview, facility document review, and facility policy review, the facility failed to keep record of the distribution for controlled substance Lorazepam (medication used to treat anxiety, insomnia, and seizures) for 1 of 6 residents (Resident #3) reviewed for medication administration. The facility reported a census 42 residents.

Inspectors wroteBased on staff interview, facility narcotic logs, clinical record review, and facility policy review, the facility failed to correctly transcribe physician orders for two controlled substances morphine sulfate concentrate oral solution (opioid narcotic used to treat severe pain) and lorazepam concentrate oral solution (benzodiazepine, which acts as a central nervous system depressant, used to treat anxiety disorders, insomnia, and seizures) which resulted in Resident #3 receiving an 8 times greater dose of morphine than ordered on 3/8/26 at 1:11 AM, followed by administration of naloxone (Narcan- nasal spray to rapidly reverse an overdose of opioid medications) on 3/8/26 at 1:45 AM, as well as, a 2 times greater dosage of Lorazepam than ordered, administered 8 times between the dates of 3/7/26 and 3/10/26 for 1 of 6 residents (Resident #3) reviewed for medication administration.

Inspectors wroteBased on observations, record review, resident, and staff interviews, the facility failed to report an allegation of abuse to the Administrator, as well as the State Survey Agency within the mandated timeframe (2 hours). This resulted in a failure to protect a resident from further harm. Resident #51 reported he told staff about a staff member who grabbed his arms, hurt him, and resulted in multiple dark purple bruises to forearms. The facility's failure to report an allegation of abuse prevented an investigation into the incident, as a result, the harm continued to occur. This failure resulted in Immediate Jeopardy to the health, safety and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/5/25 at 4:15 PM. [...]

Inspectors wroteBased on observations, record review, resident, and staff interviews, the facility failed to conduct a thorough investigation of an allegation of abuse, resulting in failure to protect a resident from further harm. Resident #51 reported he told staff about a staff member who grabbed his arms, hurt him, and resulted in multiple dark purple bruises to forearms. The facility's failure to investigate the allegation of abuse resulted in further harm to occur. This failure resulted in Immediate Jeopardy to the health, safety and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/5/25 at 4:15 PM. The facility staff removed the Immediate Jeopardy on 8/6/25 through the following actions:The facility completed education on 8/5/25 with the Abuse Coordinator regarding reporting allegations and suspicions of abuse as above. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure their staff treated residents respectfully for 2 out of 3 residents reviewed (Residents #4 and #51). Staff A, Certified Nurse Aide (CNA), and Staff B, CNA, directed Resident #4 to leave the dining room while she talked with another resident. The facility didn't have expectations or guidelines that Resident #4 couldn't be in the dining room. In addition, Staff A reported to the Charge Nurse that Resident #51 refused to get out of bed and go to the evening meal. The Charge Nurse directed Staff A to get him anyway to the dining room. The facility reported a census of 49 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews and policy review the facility failed to accommodate all residents by placing call lights in reach at all times for 1 of 6 residents (Resident #11). The facility reported a census of 49 residents.

Inspectors wroteBased on the electronic health record (EHR), facility records and staff interviews, the facility failed notify the resident or their Responsible Party when the facility initiated a change in their level of care and services for 2 of 5 residents reviewed (Residents #38 and #59). The facility reported a census of 49 residents. Findings Include:The facility completed Entrance Conference Worksheet regarding Beneficiary Notice reflected the following discharges from Medicare part A (skilled nursing facility care following a qualifying hospital stay) services on:3/10/25: Resident #38 remained in the facility.3/10/25: Resident #59 remained in the facility.1. Resident #38's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review listed their last day covered with Medicare Part A services as 3/10/25. [...]

Inspectors wroteBased on observations, record review, resident, and staff interviews, the facility failed to prevent all residents from abuse. The facility failed to provide care for Resident #51 as recommended by the Physical Therapist to facilitate transfers from bed to wheelchair and wheelchair to bed that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility reported a census of 49 residents.

Inspectors wroteBased on record review, Preadmission Screening and Resident Review (PASRR) review, and interview, the facility failed to submit a new PASRR review for 1 resident reviewed (Resident #31). After Resident #31 received a new diagnosis of bipolar disorder, the facility failed to submit a new PASRR for review. The facility reported a census of 49 residents.

Inspectors wroteBased on observation, interview, facility document review, and clinical record review, the facility failed to implement the Care Plan Interventions for 2 of 2 residents reviewed (Residents #22 and #26) for positioning. The facility failed to put in Resident #22's splints/brace as directed by the Care Plan and Therapy. In addition, the facility failed to follow the therapy recommendations as directed by Resident #26's Care Plan. The facility failed to use Resident #26's Chest Strap as directed by Therapy on multiple occasions, with 1 incident resulting in Resident #26 falling from her wheelchair. The faciltiy reported a census of 49 residents.

Inspectors wroteBased on observations, record review, resident, and staff interviews, the facility failed to revise the Comprehensive Care Plan for 1 of 3 residents (Resident #51) reviewed to meet individualized care needs. The facility staff provided care to Resident #51 according to outdated information written on a Resident List document. In addition, the facility failed to revise the Care Plan to include the Physical Therapy recommendations to meet Resident #51's needs. The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, staff, resident, and resident representative's interview the facility failed to report an incident at the time it occurred, resulting in a delay in assessment for 1 of 1 resident reviewed (Resident #4). As Staff B, Certified Nurse Aide (CNA), repositioned Resident #4 in bed, she hit her head on the siderail. Staff L, Licensed Practical Nurse (LPN), reported she learned of the incident when Resident #4 called the facility hours later and reported it herself to the Director of Nursing (DON). Staff L explained she didn't get to assess Resident #4 immediately after the incident because no one reported the incident to her until the DON did hours later. The facility reported a census of 49 residents. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. [...]

Inspectors wroteBased on observations, interviews, clinical record reviews, and facility document reviews, the facility failed to provide pressure relieving measures to a resident with a stage 3 pressure wound for 1 of 4 residents reviewed (Resident #19) for pressure wounds. The facility failed to put on Resident #19's pressure relieving boots. In addition, the facility failed to ensure Resident #19's bandage to her pressure wound remained secure. The facility reported a census of 49 residents.

Inspectors wroteBased on observations, clinical record review, facility document review, staff, resident, and resident representative interviews, the facility failed to prevent a fall for 1 of 1 resident reviewed (Resident #26). The facility failed to use Resident #26's chest strap as order by the physician, recommended by therapy, and as written on the Care Plan. While the staff adjusted the recline of Resident #26's wheelchair, she fell to the floor. At the time Resident #26 didn't wear her chest strap as directed for safety and proper seated positioning. The facility reported a census of 49 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide services to residents in accordance with acceptable infection control practices for 3 out of 3 residents reviewed (Resident #9, Resident #19 and Resident #40). While performing perineal (peri) care on Resident #9, the staff failed to complete hand hygiene after removing their dirty gloves and applying clean gloves. While performing wound care on Resident #19, the staff laid the scissors down on the bed without a barrier and then used the scissors to cut a wound dressing cover. While transferring Resident #40 with a mechanical lift after being in a shower chair, the staff removed the mechanical lift and shower chair from this resident's room without sanitizing the items after they bled on them. The facility reported a census of 49 residents.

Inspectors wroteBased on resident interviews, staff interview, call light reports and policy review, the facility failed to consistently answer call lights in a timely manner (15 minutes or less) for 3 of 3 rooms reviewed for call lights and 3 of 3 residents reviewed for call lights (Residents #1, #2 and #5). The facility reported a census of 54 residents.

Inspectors wroteBased on observation, resident and staff interview, the facility failed to treat residents with respect and dignity for 2 of 5 residents (Residents #5 and #33) reviewed for dignity. The facility reported a census of 43 residents.

Inspectors wroteBased on observation, United States Food and Drug Administration (FDA) 2022 Food Code and staff interview, the facility failed to promote good food handling when the staff touched the resident's food with dirty gloves for 4 residents observed (Residents #9, #13, #22, and #31). The facility identified a census of 43 residents.

Inspectors wroteBased on employee file review, job descriptions review and staff interview, the facility failed to ensure professional nursing staff held current and valid licenses for 1 of 2 professional nursing employee files reviewed (Staff F, Registered Nurse). The facility reported a census of 43 residents.

Inspectors wroteBased on observation, clinical record review, Center for Disease Control and Prevention (CDC) Guidance, policy review, and staff interview, the facility failed to have an adequate supply of personal protective equipment (PPE) for 1 of 1 resident reviewed for COVID 19 isolation (Resident #146). In addition, the facility failed to cover laundry during transport and ensure laundry remained free from cross contamination. The facility identified a census of 43 residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure communication devices were utilized for 2 out of 3 residents reviewed (Resident #1 and Resident #2). Resident #1 had a communication device that used a button he controlled with his head to select words and phrases on a computer. The communication device could be used when it was not on his wheelchair(w/c). The nursing staff were not educated on how to use the communication device nor did they know they could use the communication device, therefore Resident #1 was communicating with the staff by answering yes or no questions only, limiting his ability to communicate his wants and needs to his full potential. Resident #2 had a picture board with pictures of items that she would/could frequently request. [...]