Regency Harmony House Rehab & Nursing

Inspectors wroteBased on record review and interview, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes who protected and promoted resident rights under federal and state law and regulations) of discharges and/or transfers, as required for 1 of 3 sampled residents (Resident 53), reviewed for hospitalization and discharges. This failure placed residents at risk of not having an advocate during and after discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to incorporate recommended behavioral health interventions into the comprehensive care plan timely for 1 of 5 sampled residents (Resident 3) reviewed for PASRR recommendations (Preadmission Screening and Resident Review, a behavioral health evaluation that identified psychosocial needs of residents). This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow provider orders for 1 of 5 sampled residents (Resident 4) reviewed for nutrition. Specifically, Resident 4 had orders for a fluid restriction, and their oral fluid intake was not fully monitored. This failure placed the resident at risk for health consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered for 1 of 5 sampled residents (Resident 3) reviewed for medication management. This failure placed residents at risk of medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene when indicated during 1 of 1 wound care observations. Additionally, the facility failed to ensure enhanced barrier precautions (EBP, use of personal protective equipment such as disposable gowns and gloves when providing high contact types of care for residents with drains, tubes, or wounds) were implemented and followed when indicated for 2 of 3 sampled residents (Residents 1 and 23), reviewed for infection control. This failure placed residents at risk for potential unintended health consequences, the potential spread of infectious diseases or organisms resistant to antibiotics, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to protect 1 of 3 residents (Resident 2) reviewed for drug diversion (transfer of medication from the resident it was prescribed for to another person for unlawful use), from misappropriation of controlled medications (a drug or chemical that is regulated due to its potential for abuse or dependence). This failure placed residents at risk for unmet care needs, on-going misappropriation of medication, and a diminished quality of life. Review of a facility incident report dated 07/11/2025 showed that on 07/11/2025 Staff C, RN, reported to Staff A, Administrator, that on 06/14/2025 during shift exchange, Staff D, RN, and Staff C, RN were counting controlled medications when Staff C noticed a clear, 30 milliliter (about two tablespoons), medication cup containing some liquid in the top medication cart drawer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of chemical restraints for 2 of 3 residents (Resident 1 and 3) reviewed for unnecessary medications. This deficient practice placed residents at risk of experiencing unnecessary side effects such as sedation, decline in physical functioning, and placed residents at risk of experiencing an undignified life. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for choices, was afforded the right to choose their own attending physician. This failure placed the resident at risk for a diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures when they failed to report an allegation of abuse to the State Agency (SA) within the required timeframe and failed to complete a thorough investigation for 1 of 2 sampled residents (Resident 23) reviewed for abuse. This failure placed the resident and other residents at risk for repeated abuse.

Inspectors wroteBased on interview and record review, the facility failed to assess, identify triggers that might prompt a recall of previous traumatic events, and develop care planned goals and interventions for a resident who was a trauma survivor for 1 of 2 sampled residents (Resident 7) reviewed for trauma informed care. This failure placed the resident at risk for re-traumatization, psychological harm and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately date food items and ensure expired food items were disposed of when indicated during 1 of 1 inspections in the main kitchen. This failure placed the residents at risk for food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately label, and store refrigerated controlled substances in a permanently affixed compartment as required in 1 of 1 medication rooms observed for medication storage. In addition, the facility failed to maintain records to reconcile refrigerated emergency kit controlled medications in 1 of 1 medication rooms. This failure placed the facility at risk of controlled drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently maintain dish machine temperatures which placed all residents at increased risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing was appropriately maintained and changed regularly, according to professional standards of practice for 1 of 2 sampled residents (Resident 38) These failures placed the residents at risk for contact with contaminated care equipment, potential respiratory infections, and respiratory distress.

Inspectors wroteBased on interview and record review the facility failed to consistently and comprehensively assess and monitor 1 of 3 residents (Resident 1) with an inserted catheter (flexible tubing inserted into the body to remove fluid) or surgical drain (tubing used to remove excess fluids from the body). Failure to consistently assess and monitor Resident 1's surgical drain placed the resident at risk for infection and possible medical complications.