Harmony Pointe Care Center

Inspectors wroteBased on observations and interviews the facility failed to ensure that residents personal funds accounts were managed adequately for the facility and accessible to the residents. Specifically, the facility failed to ensure residents were able to access their personal funds accounts on the weekend.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a clean, comfortable and homelike environment for one (#91) of one resident out of 45 sample residents and resident rooms on four of four hallways. Specifically, the facility the facility failed to: -Ensure a homelike environment was created for Resident #91 by personalizing his room; -Ensure resident rooms and bathrooms on four of four hallways received necessary maintenance repairs; and, -Ensure hallways and dining rooms received necessary maintenance repairs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental and psychosocial well-being were provided for three (#91, #96 and #301) of three residents outside of the secured unit and all residents on the secured unit out of 45 sample residents. Specifically, the facility failed to: -Ensure Resident #91, Resident #96 and Resident #301 were provided with meaningful activities that promoted their mental and psychosocial well-being; and, -Ensure residents on the secure unit were provided with meaningful activities that promoted their mental and psychosocial well-being.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of five medication carts and one of three medication storage rooms. Specifically, the facility failed to ensure expired medications were removed from the medication carts and medication storage rooms.

Inspectors wroteBased on interviews, record review and observations the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value, palatable in taste, texture and temperature. Specifically the facility failed to ensure the resident food was palatable in taste, texture and temperature.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections throughout the facility. Specifically, the facility failed to: -Ensure housekeeping staff disinfected high touch surfaces (call lights, door handles and light switches) in resident rooms; -Ensure areas were cleaned from clean areas to dirty areas; -Ensure hand hygiene was performed appropriately during the cleaning of resident's rooms; -Ensure linen was transported and stored appropriately; -Ensure equipment used for multiple residents was cleaned regularly; and, -Ensure residents did not share cutlery and food items.

Inspectors wroteBased on observations, record review and interviews, the facility failed to honor resident choices for one (#8) of three residents out of 45 sample residents. Specifically, the facility failed to ensure Resident #8's preference was honored by getting her dressed prior to Bible study.

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident's representative when required for one (#20) of one resident reviewed out of 45 sample residents. Specifically, the facility failed to ensure Resident #20's representative was notified of her medical appointments.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents' personal privacy for one (#13) of one resident reviewed for privacy out of 45 sample residents. Specifically, the facility failed to ensure privacy during care for Resident #13 by providing the resident with a privacy curtain.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure two (#91 and #66) of two residents out of 45 sample residents were kept free from restraints. Resident #91 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease and dementia. On 8/31/24 Resident #91 was blocking the entrance to the dining room when another resident became upset and struck Resident #91 on the forehead causing a laceration. Resident #91 became upset and was pacing the hallways looking for the other resident. Due to Resident #91's behaviors, the facility staff physically restrained Resident #91 by placing him in the secured unit for the day, instead of providing him with interventions to calm him down after an altercation in which he was hit by another resident. [...]

Inspectors wroteBased on record review and interviews, the facility failed to report a resident to resident altercation that resulted in an injury to the State Survey and Certification Agency in accordance with the state law for one (#91) of one resident out of 45 sample residents. Specifically, the facility failed to report an incident of physical abuse involving Resident #91 to the State Agency in a timely manner.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan for one (#25) of two residents out of 45 sample residents for services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to ensure the comprehensive care plan addressed Resident #25's use of hearing aids and compression socks.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring or to prevent reoccurrence of pressure injuries for one (#20) of two residents reviewed out of 45 sample residents. Specifically, the facility failed to ensure physician recommendations for heel protection boots and a wheelchair cushion were implemented for Resident #20, who had a deep tissue pressure injury on her right heel.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one (#8) of one out of 45 sample residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to ensure that Resident #8 was placed on a maintenance program after therapy treatment had been discontinued.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured residents received adequate supervision and assistance to prevent accidents for one (#20) of five residents reviewed for accidents/hazards out of 45 sample residents. Specifically, the facility failed to: -Ensure staff consistently implemented fall interventions for Resident #20, which included placing the resident's call light within reach when she was in her room.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that a resident who displayed or was diagnosed with a mental disorder received appropriate interventions to correct behaviors or to attain the highest practicable mental and psychosocial well-being for one (#11) of one resident out of 45 sample residents. Specifically, the facility failed to ensure person-centered individualized interventions were implemented for Resident #11's behaviors.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#34) of five out of 45 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to: -Ensure the unapproved off label use of an antipsychotic medication (Seroquel) was not used for insomnia,for Resident #34; -Ensure the gradual dose reduction (GDR) recommendations were followed up on for Resident #34; and, -Ensure a consent was obtained for the use of the antipsychotic medication (Seroquel) for Resident #34.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#92) of three residents reviewed for pressure injuries out of 29 sample residents remained free from worsening of a pressure injury. Resident #92, was admitted on [DATE] for short term rehabilitation with a goal to return home. The resident was admitted to the facility without any skin conditions. The resident had a fall on 4/5/23 in which he sustained a right hip fracture. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one (#92) of six residents reviewed for accidents out of 29 sample residents remained as free from accident hazards as possible. Resident #92, was initially admitted for short term rehabilitation on 2/28/23 with a goal to return home. He was identified as a high fall risk and as a high elopement risk upon admission. The resident had numerous predisposing factors which included: dementia, confusion and poor safety awareness. The facility failed to develop, communicate and implement effective interventions to prevent the resident from: eloping on one occasion and falling seven times within a period of two months. The resident sustained major injuries from two out of seven falls which led to hospitalization. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide a comfortable environment and homelike environment in two out of three units. Specifically, the facility failed to keep room temperature at a comfortable level under 81 degrees Fahrenheit.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to follow up on grievances. Specifically, the facility failed to document and follow up on grievances for residents' missing clothes and items.

Inspectors wroteBased on record review and staff interviews, the facility failed to honor the preference of one (#65) out five reviewed for choices out of 29 sample residents. Specifically, the facility failed to administer a Parkinson's medication at the scheduled time per the Resident #65's request.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#27) of five out of 29 sample residents. Specifically, the facility failed to provide eating assistance for a dependent resident who required extensive assistance with eating.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#29) out of six residents out of 29 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to check Resident #29's blood pressure before administering medication according to the provider's orders.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure two (#65 and #79) of five out of 29 sample residents were provided respiratory care consistent with professional standards of practice. Specifically, the facility failed to ensure Resident #65 and #79 nasal cannula and extension oxygen tubing were dated and labeled appropriately which indicated when nasal cannula and extension tubing was changed.

Inspectors wroteBased on interviews and record review, the facility failed to provide trauma informed care in order to eliminate or mitigate triggers for one (#22) of five out of 29 sample residents. Specifically, the facility failed to identify triggers for Resident #22 post traumatic stress disorder.

Inspectors wroteBased on record review and interviews; the facility failed to provide food that accommodated resident allergies, intolerances, and preferences for one (#90) of five residents out of 29 sample residents. Specifically, the facility failed to honor and support Resident #90's diet preferences.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to change suction canisters regularly with mold observed in the suction canister of Resident #67's suctioning device.

Inspectors wroteBased on record review and interviews, the facility failed to ensure four (#66, #70, #29 and #50) of six residents reviewed for accidents out of 35 sample residents remained as free from accident hazards as possible. Resident #66, who was identified as a high fall risk, had numerous predisposing factors which included dementia, confusion, unsafe sleeping habits, and poor safety awareness. The facility failed to develop, communicate and implement effective interventions to prevent the resident from falling on multiple occasions. Due to the facility's failures, the resident sustained an acute distal ulna fracture to her left wrist subsequent to a fall on 1/18/22 requiring hospital treatment for trauma to the left wrist and pain. In addition, the facility attributed the forearm fracture to a fall on 1/5/22 (13 days previous) and 1/8/22 (10 days previous). [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide range of motion (ROM) and restorative services for two (#12 and #16) of three residents reviewed for ROM limitations without services of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #12's contracture to her left and right wrist were re-evaluated/assessed and interventions implemented on a routine basis to maintain or prevent worsening of contractures; and, -Regularly apply wrist splints to the Resident #16 as recommended by an occupational therapist (OT).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#33, #44) of three residents reviewed for dementia care of 35 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility to: -Comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #33 and Resident #44 to prevent resident-to-resident altercations; -Implement behavior tracking for Resident #33 and Resident #44 after the resident-to-resident altercation to prevent further altercations; and, -Train the staff on the secured unit to implement approaches with dementia care to keep the residents safe prior to the incident and after the incident with Resident #33 and Resident #44. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, in three out of four medication carts. Specifically, the facility failed to: -Label insulin vials and pens with an open date and store them according to manufacturer's recommendation; and, -Label inhalers and eye drops with an open date.

Inspectors wroteBased on record review, staff interviews, and observations the facility failed to ensure one (#33) of four out of 35 sample residents, remained free from resident to resident abuse. Specifically, the facility failed to ensure Resident #33 was safe from resident-to-resident altercation with Resident #44. Resident #33 called Resident #44 an expletive in Spanish. Then Resident #44 slapped Resident #33 on the face. Resident #33 sustained a lip abrasion injury.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life and care, for one (#29) of three residents reviewed out of 35 sample residents. Specifically, the facility failed to ensure Resident #29 was groomed and finger nails cleaned and trimmed.