Harmony Suites Rehabilitation and Wellness Center

Inspectors wroteBased on resident interviews, record reviews and staff interviews, it was determined that the facility failed to provide pain management according to professional standards. This was evident for 3 (Residents #59, #3, and #8) of 6 residents reviewed for unnecessary medications and pain during the annual/complaint survey. This resulted in actual harm to Resident #59.

Inspectors wroteBased on interview, review of intake #2671457, and record review, it was determined the facility failed to provide a resident with a written notice and reason for the room change before the resident was moved. This was evident for 1 (Residents #54) of 1 who had expressed a concern regarding room changes during the recertification survey.

Inspectors wroteBased on interviews, review of Intake #2801915, and facility document review, it was determined that the facility failed to provide grievance procedure information to residents or maintain an effective grievance process. This was evident during a resident council meeting and review of 2 months of grievances during the recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of admission. This was evident for 1(Resident#104) of 2 Residents care plan reviewed for tracheostomy care during the recertification survey process.

Inspectors wroteBased on observation, record review and interviews, it was determined that the facility failed to ensure that they provided communication services consistent with the resident's needs. This was evident for 1 (Resident #5) of 4 Residents with communication or sensory difficulty during the recertification survey. The Findings Included:On 05/11/2026 at 10:09 AM, during the initial tour of the survey process, the surveyor attempted to communicate with Resident #5. However, Resident #5 indicated that he/she was non-English speaking. Upon further observation of the resident's room there was no observation of any communication tool for the resident's use at bedside. On 05/11/2026 at 10:10 AM, the surveyor spoke with License Practical Nurse (LPN#17) about how staff communicated with Resident #5 and she explained that the Resident does know how to affirm basic needs; [...]

Inspectors wroteBased on observation, record reviews and interviews, it was determined that the facility failed to ensure that respiratory care needs, including tracheostomy care was provided in a manner that was consistent with professional standards of practice. This was evident for 1 (Resident #104) of 2 Residents records reviewed for respiratory and tracheostomy care during the recertification survey process. The Findings Included:Tracheostomy is a surgical hole or stoma which consists of making an incision on the front of the neck to open a direct airway to the trachea. A tracheostomy allows air to pass into the windpipe to help with breathing. On 05/11/2026 at 12:15 PM, during the initial screening phase of the survey, the surveyor observed that Resident #104 was on 2 Liters of oxygen via tracheostomy. On 05/11/2026 at 2:37 PM, a review of Resident #104's orders revealed: [...]

Inspectors wroteBased on review of Geriatric Nursing Assistant personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews at least every 12 months on 3 out of 5 personnel files reviewed during the recertification survey.

Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure accurate accountability of controlled medications. This was evident for 1 (Resident #59) of 4 residents reviewed for pain during the recertification/complaint survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident was administered medications according to a physician's order. This evident for 1 (Resident #201) out of 3 residents reviewed for medication administration.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure safe and secure storage of medications by allowing unauthorized personnel access to the medication room and medication room keys. This was evident for 1 of 2 medication rooms reviewed during the recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that staff accurately document medication administration for each resident in accordance with accepted professional standards and practices. This was evident for 3 (Resident #16, #3, and #97) of 4 residents reviewed for medication administration during the recertification survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain an effective infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. This was evident for 2 medication administration observations during the recertification survey.

Inspectors wroteBased on interviews, records review and facility investigative material the facility failed to ensure adequate supervision and failed to implement appropriate interventions to prevent one Resident (R), R16, with a history of exit seeking behaviors from elopement, when R16 exited the facility without the facility knowledge for approximately eight hours. Out of 1 of 3 sampled Residents. The census was 90. Findings Include:A review on 3/17/26 at 9:15 am of the undated facility policy Elopement Prevention and Management Overview found that elopement occurs when a resident leaves the facility or a safe area without permission or supervision, putting them at risk. If a resident who can make decisions leaves on purpose, it is not usually considered elopement unless the facility did not know the resident left or where they were. [...]

Inspectors wroteBased on record review and facility staff interviews, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's clinical status and physician-documented care for 2 of 3 sampled residents (Resident #9 and Resident #12). Facility failed to accurately code the presence of Intravenous (IV) access for Resident #9, and the administration of hypoglycemic medication, which was coded as administered when it had been placed on hold per physician orders for Resident #12.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's central venous access device for 1 of 3 sampled residents (Resident #9).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a resident received necessary care and services to maintain the highest practicable physical well-being by failing to assess, monitor and obtain appropriate treatment orders for an accessed implanted port for 1 of 3 sampled residents (Resident #9). The facility failed to initiated care from admission on [DATE] until 12/15/25, when physician orders were finally obtained, placing the resident at risk for complications including infection and loss of device patency.

Inspectors wroteBased on record review, facility policy review and staff interviews, the facility failed to implement and maintain an effective infection prevention and control program by failing to follow established standards of practice for care and maintenance of an accessed central venous device (Port-a-catheter) for 1 of 3 sampled residents (Resident #9). These failures included not performing dressing changes, not maintaining aseptic technique, and leaving an accessed device (Huber needle- special type of needle used to access implanted ports) ) in place without proper care, placing the resident at increased risk for infection.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to supervise and provide protective devices for Residents that smoked. This was found to be evident for 2 (Resident #18 & #61) out of 4 Residents observed for smoking. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified verbally and in writing of this determination at 4:05 PM on 01/29/25. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 8:37 PM on 01/29/25. On 01/30/25 the survey team confirmed the facility met the compliance date of their action plan and the Immediate Jeopardy was abated on 01/29/25. [...]

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This was evident during the initial tour of the kitchen during the annual survey.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to have routine care plan meetings for residents. This was evident for 5 (Resident #36, #76, #1, #50 and #52) out of 39 residents reviewed for care plan meetings.

Inspectors wroteBased on observations, interviews and record reviews it was determined that the facility staff failed to ensure nursing standards of practice were followed for medication-controlled drugs and security. This was found to be evident for 4 (Resident #45, #48, #77 and #384) out of 4 Residents reviewed for medication-controlled drugs and security.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to ensure that the medication error rates were not 5% or greater. This was found to be evident for 13 medications errors out of 28 opportunities that resulted in a medication error rate of 46.42% for 3 (Resident #14, #55 and #20) out of 4 residents observed for medication administration.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility staff failed to ensure medical records were complete and accurate. This was found to be evident for 5 (Resident #45, # 48, #77,#384 and #68) out of 5 Residents reviewed during the recertification survey.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to ensure a Resident was treated with dignity during care. This was found to be evident for 1 (Resident #75) out of 3 Residents reviewed for dignity during medication administration.

Inspectors wroteBased on observations, record review and interviews, it was determined the facility failed to ensure a resident had access to the facility's communication system. This was found to be evident for 1 out of 2 Residents (Resident #76) observed for accommodation of needs during the re-certification survey.

Inspectors wroteBased on record review and an interview, it was determined that the facility failed to ensure a Resident was offered information for an Advance Directive. This was evident for 1 (Resident #76) out of 1 resident reviewed for Advance Directives.

Inspectors wroteBased on Record Reviews and Interviews it was determined that the facility failed to provide Beneficiary Notices to residents discharged from Medicare Part A Services with benefit days remaining. This was evident for 1(#19) out of 3 Residents reviewed for Beneficiary Notices.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide a safe, comfortable, and homelike environment. This was found to be evident for 3 (Residents #23, #46 and #76) out of 4 Resident rooms observed for the physical environment.

Inspectors wroteBased on a review of facility-reported incident investigation, record review and interview, it was determined that the facility failed to prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation was in progress. This was evident for 1 (Resident #53) of 6 residents reviewed for abuse during the recertification survey.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to develop and implement a comprehensive care plan for 1) the resident's refusal to use palm protector and 2) the use of an anticoagulant. This was evident for 2 (Residents #32 and #53) of 39 residents reviewed for care planning during the recertification survey.

Inspectors wroteBased on observation, record review and interviews, it was determined that the facility failed to ensure that residents receive podiatry services for overgrown toenails. This was evident in 1 (Resident #52) of 1 resident reviewed for podiatry care.

Inspectors wroteBased on interviews and review of medical records, it was determined that the facility failed to provide routine appointments for vision services. This was evident for 1 (Resident #36) out of 1 resident reviewed for vision services.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to provide the prescribed treatment for limited mobility. This was evident for 1 (Resident #32) of 2 residents reviewed for positioning and mobility during the recertification survey.

Inspectors wroteBased on observations, clinical record review and staff interviews, it was determined that the facility failed to maintain respiratory therapy equipment according to professional standards of practice. This was found to be evident for 1 (#34) out of 2 residents reviewed for respiratory care during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that pain medication was given consistent with the professional standards of practice. This was evident for 1 (Resident #53) of 2 residents reviewed for pain management during the recertification survey.

Inspectors wroteBased on review of Geriatric Nursing Assistant personnel files and staff interviews, it was determined that the facility failed to conduct yearly performance reviews at least every 12 months for 2 (Staff #18 and #22) of 5 staff members reviewed.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to respond to the recommendation made by consulting pharmacist in a timely manner. This was evident for 1 (Resident #6) of 5 residents reviewed for unnecessary medications during the recertification survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that medications were stored properly. This was found to be evident for 3 (Residents #57& # 76 & 55) out of 5 Residents observed during medication storage.

Inspectors wroteBased on interviews and review of medical records, it was determined that the facility failed to provide routine dental services. This was evident for 1 (Resident #36) out of 1 resident reviewed for dental services.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure appropriate infection prevention and control practices. This was found to be evident for the laundry department and 1(Resident #20) of 4 Residents observed for infection control.

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to ensure a safe/functional/sanitary/comfortable environment. This was found to be evident in the laundry department during the annual recertification survey.

Inspectors wroteBased on observations, staff interviews, and review of facility pest control records, it was determined that the facility failed to maintain an effective pest control program. This was evident for 4 of 4 random observations made during the annual survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure waste in the outdoor garbage storage area was disposed of properly. This was evident for 1 of 1 random observation made of the facility's outdoor refuse area during the annual survey.

Inspectors wroteBased on observation and interview with staff it was determined the facility failed to provide services to maintain a clean, safe, comfortable and homelike environment. This was evident for 2 of 2 units in the facility and in the kitchen.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to accurately and appropriately identify a residents health status and representative in order to change a resident's code status. This was evident during the review of 1 of 3 (#16) residents reviewed during a complaint survey.

Inspectors wroteBased on record review and staff interview; it was determined that the facility failed to protect resident (resident #9 and #28) from physical abuse from a facility staff member. This was evident for 2 of 41 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and interviews it was determined the facility staff failed to implement measures and reasonable care to prevent loss or theft of resident's belongings. This was evident for 1 (#24) of 41 residents reviewed during the survey.

Inspectors wroteBased on record review and interviews it was determined the facility staff failed to report an allegation of misappropriation of resident belongings to the State Agency. This was evident for 1 (#24) of 41 residents reviewed during the survey.

Inspectors wroteBased on record review and interviews it was determined the facility staff failed to conduct a thorough investigation after a reports of abuse and misappropriation of resident property. This was evident for 3 (#28, #24 and #11) of 41 residents reviewed during the survey.

Inspectors wroteBased on record review and interview, the facility nursing staff failed to follow standards of practice by failing to report a resident's injury to a provider (resident #31). This was evident for 1 out of 41 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview with resident and facility staff, it was determined that the facility failed to provide care to a resident that is dependent on staff for activities of daily living (ADL). This was evident during the review of a complaint for 1 of 4 (#35 ) residents related to quality of care.

Inspectors wroteBased on record review and interview with staff it was determined that the facility staff failed to ensure that residents received proper foot care and treatment. This was evident for 1 (#34) of 41 residents reviewed during the survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to have a discharge summary on the medical record. This was evident for 1 of 3 (#20) residents reviewed for discharges during a complaint survey.

Inspectors wroteBased on observation and interview with staff it was determined the facility failed to ensure a functioning call system to allow residents to call for staff assistance in each toilet and bathing facility. This was evident for 2 of 4 resident bathrooms observed.

Inspectors wroteBased on observation and staff and resident interview, it was determined that the facility failed to maintain an effective pest control program. This deficient practice had the potential to impact all residents.

Inspectors wroteBased on the review of the residents' clinical records, a review of the facility's policy and procedures related to smoking, observations of residents and staff practices, and interviews with residents and facility staff, it was determined that the facility failed to consistently implement their smoking policy. This finding was evident for 3 of 3 residents reviewed for smoking (Resident #10, #21, #69).

Inspectors wroteBased on surveyor review of the clinical record and interview with a resident and facility staff, it was determined that the facility staff failed to conduct timely quarterly care plan conferences with 1 of 22 residents selected for review during the survey (Resident #72).

Inspectors wroteBased on the review of residents' clinical records and interviews with facility staff, it was determined that the facility staff failed to ensure nursing standards of practice for 2 of 22 residents selected for review during the survey. This finding was evident for 2 of 22 residents selected during the survey (Residents #20 and #245).

Inspectors wroteBased on surveyor review of the clinical record, interview of the resident's representative and facility staff, it was determined that the facility staff failed to ensure that Resident #47 received outside services to manage a health condition for 1 of 22 residents selected for review during the survey (Resident #47).

Inspectors wroteBased on the review of the clinical record and interview with Hospice staff and the facility's staff, it was determined that the facility failed to ensure complete and accessible documentation in the clinical records for 2 of 22 residents selected for review during the survey (Residents #20 and #79). 1. On 02-03-2020 the review of Resident #20's clinical record revealed the resident receives nursing and supportive services from a community Hospice agency. Further review of the record revealed documentation by Hospice of monthly summaries for the resident. On 02-03-2020 at 1:00 PM an interview with the Director of Nursing revealed that a Hospice nurse makes weekly visits to the facility, conducts assessments and collaborates with the nursing staff on Resident #20's care. [...]

Inspectors wroteBased on surveyor review of the administrative records, facility's policies and procedure and interview with the facility staff, it was determined that the facility failed to ensure the requirements for the Quality Assessment and Assurance (QAA) committee meetings were met. This finding was identified during the QAA review.

Inspectors wroteBased on surveyor review of the clinical record, review of the Beneficiary Protection Notifications and interview with facility staff, it was determined that the facility failed to provide 1 of 1 resident selected for the Beneficiary Protection Notification review with the NOMNC (Notice of Medicare Non-Coverage) and SNFABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) in a timely manner (Resident #60).