Harmony Utica Ridge

Inspectors wroteBased on clinical record review, resident and staff interview, and facility policy review, the facility failed to use non-pharmacological interventions prior to the administration of a medication prescribed for anxiety which caused for 1 of 1 resident (Resident #8) reviewed for chemical restraints to experience hypersomnolence (excessive sleepiness). The facility reported a census of 91.

Inspectors wroteBased on clinical record review, staff and resident interview, and facility policy review, the facility failed to document the outcome of weekly skin assessments and implement a new wound care order in a timely manner for 1 of 7 residents (Resident #1) reviewed for pressure ulcer care. The facility reported a census of 91.

Inspectors wroteBased on observation, clinical record review, facility policy review, and staff interviews, the facility failed to serve the correct portion size of the protein entree for 8 of 9 (Resident #1, #31, #43, #54, #77, #79, #89 and #96) residents with a mechanical soft diet order. The facility identified a census of 89 residents.

Inspectors wroteBased on observation, kitchen record review, facility policy review, the US Food Code (2017) and staff interviews, the facility failed to maintain clean and sanitary equipment in the main kitchen and in a kitchenette. The facility identified a census of 89 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, staff and resident interviews the facility failed to determine if 1 of 1 resident (Resident #4) with an inhaler at their bedside could safely self-administer the medication. The facility reported a census of 89 residents.

Inspectors wroteBased on clinical record review, Centers for Medicare and Medicaid Services (CMS) Long-term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual and staff interviews, the facility failed to ensure he Minimum Data Set (MDS) assessments coded accurately to reflect resident use of an indwelling catheter and use of an antidepressant and hypnotic for 2 of 2 resident (Resident #32 and Resident #83) reviewed. The facility reported a census of 89 residents. Findings Include: 1. Review of Resident #32's MDS assessment, dated 5/4/26, revealed an admission date of 4/29/26. The list of diagnoses included: neurogenic bladder (lose of control due to nerve damage); multiple sclerosis and depression. The MDS identified Resident #32 with no appliance (such as a catheter or ostomy). [...]

Inspectors wroteBased on observation, clinical record review, facility policy review and staff interview the facility failed to provide complete shaving care for 2 out of 2 residents dependent residents (Resident#1 and Resident #67) reviewed for activities of daily living care. The facility reported a census of 89 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, the facility failed to complete physician ordered treatments for 1 of 4 residents (Resident #4) reviewed for wound care. The facility failed to reported a census of 89 residents.

Inspectors wroteBased on observation, clinical record review and staff interview the facility failed to implement pressure reducing interventions per the wound nurse practitioner's recommendations for 1 of 2 (Resident #11) reviewed for pressure injuries. The facility identified a census of 89 residents. The CMS RAI Manual defines the following pressure injury (PI) (a pressure ulcer/injury is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful) stages:Stage 1: Non-blanchable Erythema: Intact skin with persistent red/blue/purple discoloration; color does not blanch. Stage 2: Partial Thickness Loss: Shallow, open wound with red-pink bed (no slough) or a serum-filled blister. Stage 3: [...]

Inspectors wroteBased on observation, clinical record review, manufacturer guidelines and staff interviews, the facility failed to use the correct size full-body mechanical lift sling based on resident weight during a transfer for 1 of 3 (Resident #67) reviewed for accidents. The facility reported a census of 89 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interviews, the facility failed to respond to a call light in a timely manner for 1 out of 4 residents (Resident 3#) reviewed for call lights. The facility reported a census of 89 residents.

Inspectors wroteBased on observations, clinical record review, facility policy review, and staff interviews, the facility staff failed to implement Enhanced Barrier Precautions when doing wound care for 1 of 4 residents (Resident #83) reviewed for infection control. The facility reported a census of 89 residents.

Inspectors wroteBased on review of the Certification and Survey Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), facility policy review, and staff interviews, the facility failed to ensure an effective QAPI program to address previously cited deficiencies which resulted in five deficiencies being re-cited during the current Health Recertification survey. The facility reported a census of 89 residents.

Inspectors wroteBased on Payroll Based Journal (PBJ) review and staff interview, the facility failed to ensure accurate reporting of weekend staffing hours, resulting in a excessively low weekend staffing trigger for Quarter 1 2025 (October 1-December 31). The facility reported a census of 88 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to discard expired lettuce from refrigerator storage and failed to record evening meal temperatures for 3 of 7 days reviewed. The facility reported a census of 88 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interviews, the facility failed to notify the provider of a weight change of 3 pounds or more in one day as ordered for 1 of 1 resident (Resident #67) in sample reviewed. The facility reported a census of 88 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for 4 of 4 residents reviewed for quarterly MDS timeliness (Resident #1, Resident #10, Resident #34, Resident #61). The facility reported a census of 88 residents.

Inspectors wroteBased on staff interview and clinical record review, the facility failed to ensure accuracy of Section N, Medications, on the Minimum Data Set (MDS) assessment for 2 of 5 residents reviewed for unnecessary medications (Resident #26, Resident #34). The facility reported a census of 88 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, the facility failed to include dialysis services and use of an anticoagulant in the Care Plan for 2 of 3 (Resident #3 and Resident # 83). The facility reported a census of 88 residents.

Inspectors wroteBased on observation, staff and resident interview, clinical record review, and facility policy review, the facility failed to follow physician orders for treatment of left lower leg surgical site for 1 of 3 residents (Resident #87) reviewed for non-pressure injuries, when staff used an alternate treatment application to wound site during observation of wound care. The facility reported a census of 88 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure foot pedals were utilized when residents transported in a wheelchair, and failed to ensure fall interventions were consistently implemented for 3 of 4 residents reviewed for accidents (Resident #16, Resident #66, Resident #310). The facility reported a census of 88 residents.

Inspectors wroteBased on observations, clinical record review and staff interviews, the facility failed to ensure a indwelling catheter bag and tubing maintained in a position minimize the risk of a urinary tract infection for 1 of 1 residents (Resident #43) reviewed. The facility reported a census of 88 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to ensure availability of scheduled medications for a new administration and timely availability of an as needed pain medication for 1 of 3 residents (Resident #104) reviewed for pain management. The facility reported a census of 88 residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to implement Enhanced Barrier Precautions for one of one residents reviewed with an indwelling catheter (Resident #43). The facility reported a census of 88 residents.

Inspectors wroteBased on clinical record review, staff interviews, and the facility policy, the facility failed to provide documentation residents refused/accepted pneumococcal vaccine to 3 of 5 residents reviewed (Resident #16, #10, and #33). The facility reported a census of 88 residents.

Inspectors wroteBased on observation, clinical record review and staff interview, the facility failed to implement infection control standards during wound care. After providing wound care, nursing staff did not remove an isolation gown prior to exiting a residents room to access a common medication cart drawer for supplies, and did not change gloves between wound care tasks for one of three residents observed (Resident #4). The facility reported a census of 84 residents.

Inspectors wroteBased on observation, clinical record review, resident, family and staff interviews, the facility failed to provide a wound assessment and intervention for 1 of 3 residents reviewed (Resident #16). A bandage over a wound to the right buttocks on Resident #16 was identified by nursing staff on [DATE] without prior documentation and without provider notification for a treatment order. Resident #16 required hospitalization on [DATE] for sepsis, an infected wound, Methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli (E.coli) and a Urinary Tract Infection (UTI). Resident #16 expired on [DATE]. This deficient practice resulted in an Immediate Jeopardy to the health and safety of residents who resided at the facility. The facility identified a census of 89 residents. [...]

Inspectors wroteBased on clinical record review, and staff interview the facility failed to submit a Change in Status Preadmission Screening and Resident Review (PASRR) assessment after two new mental health diagnoses were determined for 1 of 1 residents (Resident #38) reviewed. The facility reported a census of 89 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and resident and staff interview the facility failed to complete nursing assessments and monitoring of a resident before and after outpatient dialysis for 1 of 1 resident reviewed (Resident #72). The facility reported a census of 89 residents.

Inspectors wroteBased on medical record review, family and staff interview and facility failed to supervise and ensure a compromised resident (left sided weakness/paralysis) was safe from accidents when turned in bed, and the result was the subdural hematoma and death. (Resident #14). The facility reported a census of 99 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 2/22/24 at 1:50 PM. The IJ began on 2/20/24. Facility staff removed the Immediate Jeopardy on 2/22/24 at 4:34 PM by completing the following; a. At the direction of the center Quality Assessment and Assurance (QA&A) Committee, an investigation was initiated which included interviewing employees and interviewing like residents residing in the center beginning 2/20/24. b. [...]

Inspectors wroteBased on observation, medical record review, family and staff interviews and facility policy review, the facility failed to provide nail care to the feet of 3 of 3 residents reviewed (Residents #3, #12 and #13) and failed to provide showers twice weekly to 3 of 6 residents reviewed (Residents #14, #16, #17). The facility reported a census of 99 residents.

Inspectors wroteBased on medical record review, resident and staff interviews and facility policy review, the facility failed to ensure staff treated residents with dignity and respect for two of four residents reviewed (Residents #4 and #7). The facility reported a census of 99 residents.

Inspectors wroteBased on observation, record review, family and staff interview, the facility failed to update the Care Plan for one of three residents reviewed (Resident #15). The facility reported a census of 99 residents.

Inspectors wroteBased on clinical record review, staff interview and hospital record review, the facility failed to document a complete assessment of two of four residents reviewed (Residents #5 and #13). The facility reported a census of 99 residents.