Harmony Village of Beverly Hills

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in foodborne illness and cross-contamination for all residents that consume food from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to maintain the exterior dumpster area in a clean manner. This deficient practice had the potential to affect all residents, staff and visitors.

Inspectors wroteBased on interview and record review the facility failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was provided and completed for two (R1 and R19) of three residents reviewed for beneficiary notification, resulting in the residents and/or their representatives not being informed timely of private pay charges for continued services while they remained in the facility.

Inspectors wroteThis citation pertains to intakes 2738135 and 2738724. Based on interview and record review, the facility failed to provide supervision for one (R603) of five residents reviewed for accidents, resulting in R603, with a history of severe mental illness, homelessness and frost bite, exiting the facility. This resulted in an Immediate Jeopardy when R603 exited the facility unbeknown to the facility staff, was picked up by Police on 2/8/26 at 1:33 AM and not identified as missing by facility staff until 2/8/26 at approximately 2:50 PM (approximately 13 hours later). Due to the deficient practice, R603 and additional residents at risk for elopement had the increased likelihood for serious harm, serious injury, and/or death including hypothermia, frost bite, hand other health hazards related to being outside in extreme cold weather unsuprevised.

Inspectors wroteThis citation has two deficient practice statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to prevent a fall with significant injury for one (R39) of two residents reviewed for falls, which resulted in a head injury, sutures, and ongoing pain and discomfort.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, homelike environment resulting in odors (R42) and equipment that does not work properly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was accessible to the resident for one (R32) of three residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure chemical restraints were not utilized for staff convenience, and without identification of non-pharmacological approaches attempted for one (R42) of one resident reviewed for psych/opioid medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain medication was administered per physician's orders and documentation in the record was accurate in accordance with nursing professional standards for one resident (R31), of one resident reviewed for nursing professional standards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain medications were administered as ordered for one resident (R31), of one resident reviewed for pain, resulting in repeated complaints of pain and discomfort.

Inspectors wroteBased on observation and interview, the facility failed to maintain mechanical ventilation, resulting in lingering odors and uncirculated air, affecting four residents that share a bathroom in room [ROOM NUMBER] and 119, and throughout the center hallway and therapy gym.

Inspectors wroteThis citation relates to Intake 1291048. Based on observation, interview, and record review, the facility failed to protect one Resident's (R204) right to be free from abuse mistreatment of two residents reviewed for abuse, when R204 was intimidated by a former staff member (witnessed by R203) with verbal aggression and a threatening gesture.

Inspectors wroteThis citation relates to Intake 1291048. Based on interview and record review, the facility failed to report an abuse mistreatment incident for one Resident (R204) of two residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate infection control practices, hand hygiene, during medication administration observations for five (R4, R6, R10, R25, R27) of five residents resulting in the increased likelihood for the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent the development of a pressure ulcer, ensure the facility accurately assessed/identified the wound timely and accurately implemented treatment for one (R27) of two residents reviewed for pressure ulcers, resulting in the development of a Stage IV (full-thickness skin and tissue loss) pressure ulcer to the bilateral buttocks that required an extensive hospital stay and a diagnosis of osteomyelitis (bone infection).

Inspectors wroteThis citation related to Intake #: MI00150321. This citation has two deficient practice statements. Deficient Practice Statement #1 Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent two physical resident-to-resident incidents for three Residents (R7, R13, R23) of three residents reviewed for incidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one (R25) of one resident reviewed for nutrition received nutritional supplements as ordered, resulting in the potential for weight loss and overall decline in their condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent. Two medication errors were observed for R10 from a total of 30 opportunities reviewed during medication administration, resulting in an error rate of 6.67%.

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate medication storage and labeling for medications in two of two medication carts reviewed and one residential room.

Inspectors wroteBased on record review and interview, the facility failed to ensure laboratory services for a urine culture/sensitivity test were received timely resulting in administering a resistant antibiotic for a Urinary Tract Infection in one resident (R27) of one reviewed for laboratory services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist and ensure timely dental services (to obtain replacement dentures) for an extended period (approximately 6 months) for one (R6) of one resident reviewed for dental services resulting in the potential for avoidable decline in nutrition, overall health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate medication orders and clarify ambiguous orders with the physician for one (R16) of one resident reviewed for professional standards.

Inspectors wroteThis citation is pertains to Intake #MI00145426. Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement elopement policies for one (R8) of one residents reviewed for elopement, resulting in a cognitively impaired resident being let out of a secured back door to the facility, unsupervised. R8 was found by the police, about two miles away from the facility.

Inspectors wroteThis citation pertains to intake #MI00145538. Based on interview, and record review, the facility failed to ensure all controlled substances were accounted for and accurately documented for one (R226) of five residents whose medications were reviewed, resulting in the unaccountability of the resident's controlled medications and the potential for diversion.

Inspectors wroteThis citation pertains to intake #s MI00141144, MI00141160, MI00142537, MI00143525, MI00143276, and MI00144073. Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment, affecting all 81 residents that reside in the facility, including R810, R814 and R815.

Inspectors wroteThis citation pertains to intake #MI00140360. Based on interview and record review the facility failed to implement their grievance policy and promptly address, investigate, follow up, and resolve concerns reported to the facility staff for one (R816) of two residents reviewed for grievances.

Inspectors wroteThis citation pertains to intake #MI00141144. Based on observation, interview and record review, the facility failed to maintain sanitary conditions in the kitchen, label/date food items, and discard expired food items. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteThis citation pertains to intake #s MI00141144, MI00143525, and MI00144073. Based on observation, interview and record reviews, the facility failed to ensure appropriate infection control practices with regards to linen storage. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteThis citation pertains to intake #MI00141144. Based on observation, interview and record review, the facility failed to maintain an effective pest control program, resulting in visible gnats in the rooms of R814, R815, and throughout the entire facility.

Inspectors wroteThis citation pertains to intake #'s MI00141071, MI00142083 and MI00143861. Based on observation, interview and record review the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for five residents (R807, R808, R809, R810 and R819) of seven residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteR807 and R808 On 5/14/24 a FRI (Facility Reported Incident) submitted to the State Agency was reviewed which alleged R807 attempted to get into R808's bed, touch their leg and made inappropriate and sexual comments on 10/29/23. R807 On 5/14/24 the medical record for R807 was reviewed and revealed the following: R807 was initially admitted on [DATE] and had diagnoses including Dementia, Anxiety and legal blindness. R807's MDS with an ARD of 10/28/23 revealed a BIMS score of zero indicating severely impaired cognition. A Nursing progress note dated 10/29/23 revealed the following: Nursing Progress Note Late Entry: . Resident touched his roommate on his leg upsetting roommate who felt it was a sexual advance Responsible party notified , Physician notified, Administrator notified , DON (Director of Nursing) notified . Immediate intervention implemented: roommate moved to another room . [...]

Inspectors wroteThis citation pertains to intake #MI00143431. Based on observation and interview, the facility failed to ensure that essential electrical equipment was maintained in safe operating condition. This has the potential to affect multiple residents throughout the facility.

Inspectors wroteThis citation pertains to intake #s: MI00141037 and MI00143377. Based on interview and record review the facility failed to inform a legal resident representative of changes in mental capacity and Physician ordered medication changes in a timely manner for one resident (R818) of one residents reviewed for notification of changes.

Inspectors wroteThis citation pertains to intake #MI00142887 Based on observation, interview and record review the facility failed to prevent an unauthorized exit from the facility and appropriately assess for elopement risk for one resident (R813) of seven residents reviewed for accidents/supervision.

Inspectors wrotethis citation pertains to intake MI00142652 Based on observation, and interview the facility failed to provide a clean homelike environment including for one Resident (R700), free from avoidable odors and gnats.

Inspectors wroteThis citation pertains to intake MI00141246,MI00140964 Based on interview, and record review the facility failed to protect two resident's(R670 and R690) rights to be free from physical abuse by R680.

Inspectors wroteThis Citation has two Deficient Practice Statements (DPS) and pertains to intakes MI00141808 and MI00140623. DPS1 Based on observations, interview and record review the facility failed to ensure, monitoring, supervision and interventions for three of three residents (R600, R610 and R620) with known substance use disorders.

Inspectors wroteThis citation pertains to intake #MI00139279 This citation has three deficient practices Deficient Practice #1 Based on interview and record review the facility failed to establish a comprehensive infection control program that identified resident infections, calculated monthly infection rates, tracked and trended infections, utilized laboratory and pharmaceutical data, and ensured departmental surveillance and staff education on infection control. This deficient practice had the potential to affect all 87 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident dignity for four residents (R#'s 17, 28, 44, and 93) of four residents reviewed for dignity, three additional residents (R2, R49, and R58) and several members who participated in the group meeting who wished to remain anonymous.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure fresh water was provided and water was within reach for eight residents (R#'s 32, 12, 90, 56, 75, 13, 37, 16, and 44) of 87 residents reviewed for accommodation of needs.

Inspectors wroteThis citation pertains to Intake Number(s): MI00138819 and MI00139774. Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for multiple residents (including R5, R23, R88, R35, R93,R18, R54, R17) in multiple resident rooms and hallways throughout the facility.

Inspectors wroteThis citation pertains to Intakes MI00138819 and MI00139871. Based on interview, and record review, the facility failed to ensure there was sufficient nursing staff to provide care and services to the residents. This had the ability to affect all residents in the facility.

Inspectors wroteThis citation pertains to intake MI139844. Based on observation, interview, and record review, the facility failed to provide a functional call system that provides direct communication from the residents to the caregivers, in the [NAME] and East hall shower rooms. This deficient practice had the potential to affect all residents that utilize the [NAME] and East hall shower rooms.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the State Agency for two residents (R93 and R252) of 15 residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure care conferences were conducted regularly for one (R62) of 18 residents reviewed for care planning.

Inspectors wroteThis citation pertains to intake #MI00139774. Based on interview and record review, the facility failed to address a change of condition and ensure a timely transfer to the emergency department after a fall for one resident, (R247) of one resident reviewed for transfer the the emergency room.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure smoking supplies were securely stored for one (R45) of one resident reviewed for smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure catheter care for one resident (R21) of one resident reviewed for catheter care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for a feeding tube for one resident (R82) of three residents reviewed for feeding tubes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment and services for a tracheostomy for one resident (R82) of one resident reviewed for tracheostomy care.