Resolve Harmony Center, LLC

Inspectors wroteBased on a review of clinical records, staff and resident interviews, and a review of facility policies and procedures, the facility failed to ensure that one (#1) out of 3 sampled residents was not abused by another resident (#2). The Universe was 62. The deficient practice could lead to physical and psychosocial harm to residents.

Inspectors wroteBased on clinical record review, staff interviews, review of facility documentation and policies, the facility failed to protect the rights of one resident (#2) to be free from physical abuse by another resident (#3). The deficient practice could result in further physical abuse of residents when appropriate actions are not taken.

Inspectors wroteBased on clinical record reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to protect the right's of two of four sampled resident's (#1, #2) to be free from physical abuse by another resident. The deficient practice could result in the residents being in an unsafe environment. Findings Include: -Regarding Resident #1Resident #1 was admitted on [DATE], with a diagnosis that included cirrhosis of the liver, Parkinsonism, hydrocephalus, bipolar disorder, and mild cognitive impairment of uncertain. [...]

Inspectors wroteBased on the review of the clinical records, staff interviews, and review of facility's policy and procedure, the facility failed to ensure PASARR (pre-admission screening and resident review) were updated appropriately and accurately submitted, when applicable, for six of 8 sampled residents (#17, #24, #26, #30, #40, and #42). The deficient practice could result in residents' medically related social and emotional needs not being met. The census was 50.

Inspectors wroteBased on the interview, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one of 21 sampled residents (Resident #37) was free from accidents and hazards, in regards to safe smoking. The deficient practice can lead to the possibility of burns, fires, smoke inhalation, serious injury, death, and potentially cause facility-wide danger. The sample size is 21. The census was 50. Regarding Resident #37:Resident #37 was admitted to the facility on [DATE], with the diagnosis that included encounter for immunization; multiple sclerosis, unspecified; encounter for therapeutic drug level monitoring; schizoaffective disorder, bipolar type; mood disorder due to known physiological condition, unspecified; generalized anxiety disorder; and other muscle spasm. [...]

Inspectors wroteBased on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to implement its smoking policy for three residents (#12, #26, and #41). The deficient practice could result in inadequate smoking interventions due to the lack of an assessment and put residents at increased risk for smoking-related incidents. The sample size is 21. The census was 50.

Inspectors wroteBased on clinical record review, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to transmit Minimum Data Set (MDS) data for one resident (# 16) within the regulatory timeframe of 14 days after admission. This deficient practice could result in delayed identification of potential risks and care needs. The sample size was one. The universe was 50. Findings Include:Resident # 16 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, atrial fibrillation, and bipolar disorder. The admission MDS, dated [DATE], revealed the Assessment Reference Date (ARD/Observation end date) as October 26, 2025. The signature of the Registered Nurse Assessment Coordinator verified assessment completion on November 3, 2025. [...]

Inspectors wroteBased on clinical record review, interviews, facility documentation and policy, the facility failed to ensure that one resident (#2) received physician-ordered testosterone therapy per physician's order. This deficient practice could result in the worsening of a resident's underlying condition. The sample size was five. The universe was 50.

Inspectors wroteBased on clinical record review, interviews, facility documentation, and policy review, the facility failed to ensure one resident (Resident #5), with a history of Substance Use Disorder (SUD), was not administered pain medications outside provider-ordered parameters. This deficient practice places residents at risk for adverse drug reactions and dependence. The sample size was 5. The universe was 50.

Inspectors wroteBased on an observation, staff interviews, and the facility policy and procedures, the facility failed to ensure one medication cart was secured when left unattended. The deficient practice could result in residents, visitors and/or staff members having unrestricted access to medications.

Inspectors wroteBased on interviews, clinical record review, and review of facility policy and procedures, the facility failed to protect the rights of one of three sampled residents (#38) to be free from abuse by another resident (#21). The deficient practice resulted in a resident-to-resident physical altercation with documented injuries and had the potential to result in ongoing abuse and further harm to other residents.

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#4) to be free from abuse by another resident (#6). The deficient practice could result in further resident abuse.

Inspectors wroteBased on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of residents to be free from abuse by another resident (#777, #222, #444). The deficient practice could result in residents being harmed physically and emotionally. -Regarding Resident to Resident altercation between Resident #1001 and #777: -Resident #1001 was admitted to the facility on [DATE] and discharged on May 22, 2023. Diagnoses included schizoaffective disorder depressive type, dysphagia following cerebral infarction, and human immunodeficiency virus (HIV). The care plan dated April 10, 2023 revealed that the resident was involved in an altercation with another resident. He rammed his chair into the resident's feet. The resident will not be involved in another altercation with another resident through the next review date. [...]

Inspectors wroteThe facility failed to ensure that one resident (#1000) was treated with dignity and respect by another resident. Based on documentation, staff and resident interviews, the facility policy and procedures, the facility failed to ensure that one resident (#1000) was treated with dignity and respect by another resident (#1001). The deficient practice could result in psychosocial harm.

Inspectors wroteThe facility failed to update the fall care plan for one resident. Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to update the fall care plan for one resident (#4). The deficient practice could result in residents not receiving the care needed to prevent further accidents.

Inspectors wroteThe facility failed to ensure that one resident's (#484) received services to meet professional standardsBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#4) received services that met professional standards. The deficient practice could result in residents not receiving the care needed in a timely manner.

Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy, the facility failed to protect the rights of four out of the seven sample residents to be free from abuse by another resident. The deficient practice could result in other residents being abused. Findings Include: - Regarding a resident-to-resident altercation that occurred on June 20, 2025 involving Resident # 35, Resident #13, and Resident #72. -Regarding Resident #35Resident # 35 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, urinary tract infection, and heart failure. A quarterly MDS (Minimum Data Set) assessment, dated February 2, 2025, revealed a BIMS (Brief Interview for Mental Status) score of 12, indicating moderately impaired cognition. [...]

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to report alleged violations involving abuse for two residents (#35 and #13 ). The deficient practice resulted in allegations of abuse not being reported, not investigated, and residents not being protected from further abuse. Regarding a resident-to-resident altercation that occurred on June 20, 2025 involving Resident # 35, Resident #13, and Resident #72. -Regarding Resident #35Resident # 35 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, urinary tract infection, and heart failure. A quarterly MDS (Minimum Data Set) assessment, dated February 2, 2025, revealed a BIMS (Brief Interview for Mental Status) score of 12, indicating moderately impaired cognition. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#2) did not abuse another resident (#4). The deficient practice could result in residents being physically harmed. Findings Include: - Regarding Resident #2: Resident #2 was admitted on [DATE] with diagnoses that included dementia, chronic ischemic heart disease, chronic obstructive pulmonary disease and major depressive disorder. An admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 13, which indicated the resident is cognitively intact. A progress noted dated February 16, 2023 at 03:10 a.m. revealed that Resident #2 was involved in an altercation with Resident #4 outside on the patio. Resident #4 named Resident #2 as the resident that knocked her tooth out and that Resident #4 hit Resident #2 with a stick. [...]

Inspectors wroteBased on clinical record reviews, resident and staff interviews, facility documentation, policy, and procedures, the facility failed to ensure that residents (154), (145),(125) and (D1) were free from resident-to-resident abuse.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to maintain a safe, clean, and comfortable environment for 2 of 2 sampled residents (#35 and #39), and failed to maintain a clean and sanitary environment in 3 of 3 shower rooms. The deficient practice could result in spread of infection, pest infestation, and resident rooms not having a homelike environment. Findings Include: - Regarding the shower rooms: On December 13, 2024, at 12:49 PM, a walk-through was conducted in the facility's north shower room with a certified nursing assistant (CNA/ Staff #82), while all of the shower rooms were not in use by residents. In the shower stall area, on the caulk line between the shower wall and shower basin area underneath the water spout, a black and brown to orange appearing residue substance was noted. [...]

Inspectors wroteBased on observation, staff interviews, and policy documentation the facility failed to ensure that the daily nurse staffing information posted were accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information.

Inspectors wrote-Regarding Resident #39: Resident #39 was admitted on [DATE], with diagnoses that included schizophrenia, anxiety disorder, depression, repeated falls, and heart failure. A physician order dated December 05, 2024, indicated for Linezoid-0.9% sodium chloride parenteral solution; 600 mg/300 mL, to be given intravenously twice a day. There was no evidence of an order for Enhanced Barrier Precautions (EBP), or any other type of transmission-based precautions for Resident #39. A care plan revised December 04, 2024, for IV central line indicated that the resident will exhibit no signs of IV complications during period of intravenous requirements and post removal. There was no evidence of a care plan focus for EBP, or any other transmission-based precautions. [...]

Inspectors wroteBased on observations, facility documentation, staff interviews, and Center for Disease Control (CDC) guidelines, the facility failed to execute an antibiotic stewardship program. The facility census was 59 residents. The deficient practice could result in improper antibiotic use and adverse outcomes to residents.

Inspectors wroteBased on observations, staff interviews, review of facility records and policies and procedures, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. The deficient practice could result in ongoing pest problems and residents not having a homelike environment.

Inspectors wroteBased on observations, resident and staff interviews, clinical record review and policy, the facility failed to ensure that dignity was maintained for one resident (#28). The deficient practice has the potential for additional residents to be treated with a lack of dignity and respect.

Inspectors wroteRegarding Resident #43: Resident #43 was initially admitted on [DATE] with diagnoses that included anxiety disorder due to known physiological conditions, schizophrenia, mood disorder and major depressive disorder. A care plan initiated on October 27, 2023 and revised November 11, 2024 revealed that the resident was at risk for self-harm related to feelings of helplessness, sadness, hopelessness, hearing voices, suicidal ideation, depression, and anxiety secondary to psychiatric disorder schizophrenia. Interventions included encouraging follow-up with the community, and to notify providers for any issues. The antipsychotic drug therapy care plan initiated on October 27, 2023 revised November 10, 2024 included interventions that included to administer medications as ordered and monitor/document side effects, and monitor/document behaviors. [...]

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was notified of a medication not administered according to professional standards for one of one sampled resident (#19). The deficient practice could result in a resident not receiving medication to meet their needs and the physician not being aware of the resident's status. -Findings Include: Resident #19 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease, schizophrenia, bipolar disorder, and drug induced subacute dyskinesia. A care plan dated April 16, 2024, indicated that Resident #19 has tardive dyskinesia (movement disorder), and will participate in self care activities at the highest level of independence. [...]

Inspectors wroteBased on clinical record review, staff interviews, review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#46). The deficient practice could result in residents not receiving necessary services for oral and dental care.

Inspectors wroteBased on observations, staff interviews, and policy reviews, the facility failed to ensure food items were not expired and the vent across from tray line was clean. The deficient practice could increase the risk of foodborne illness.

Inspectors wroteBased on observation, clinical record review, interviews, and review of facility policies, the facility failed to ensure three residents (#35, # 39, and #216) was provided a means to communicate with the staff by having a call light accessibility. The deficient practice could result in residents not having the means to communicate with staff.

Inspectors wroteBased on personnel file review, staff interviews, and facility policy review, the facility failed to maintain an effective training program for three of ten sampled staff (#62, #75, and #82). The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm.

Inspectors wroteBased on personnel file review, staff interviews, and facility policy review, the facility failed to ensure three of ten sampled staff sampled staff (#62, #75, and #82) received ongoing education on residents' rights. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm.

Inspectors wroteBased on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of ten sampled staff sampled staff (#62 and #75) received ongoing education on abuse, neglect, exploitation, and providing care to those with Alzheimer's or other dementia. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm.

Inspectors wroteBased on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of ten sampled staff sampled staff (#62, #75, and #82) received ongoing education infection control. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#3) was not neglected. The deficient practice could result in residents not receiving the care and services needed to improve and maintain health.

Inspectors wroteBased on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure that comprehensive care plans were developed for two residents (#166 and #30). The deficient practice could result in residents needs based on the comprehensive assessment not being met.

Inspectors wroteBased on clinical record review, staff interviews, facility policy and hospital record review, the facility failed to ensure adequate supervision was provided for one resident (#166) related to illicit drug use. The deficient practice could result in a decline in the resident's health condition or death.

Inspectors wroteBased on a review of the facility documentation, staff interviews and policy review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, seven days a week; and, failed to designate a registered nurse to serve as the director of nursing (DON) on a full-time basis. The deficient practice could result in not meeting the critical needs of the residents.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to provide one resident (#40) a clean and homelike environment by not storing boxes for activities in the room.

Inspectors wroteBased on clinical record review, staff interviews, facility document and policy and procedure review, the facility failed to ensure that one resident (#23) was not sexually abused by another resident (resident #30). The deficient practice could result in residents being inappropriately touched.

Inspectors wroteBased on staff interviews, review of facility documentation, State Agency Database, policy and procedures, the facility failed to implement their policy on reporting and investigation of an allegation of misappropriation of property for one resident (#14). The deficient practice could result in misappropriation of property to continue and not prevented.

Inspectors wroteBased on review of the clinical record, facility documentation, review of the State Agency database, staff interviews and review of policy and procedure, the facility failed to ensure one allegation of misappropriation of property for one resident (#14) was thoroughly investigated. The deficient practice could result in allegations of abuse not being investigated and abuse occurring in the facility.

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to ensure that the daily nurse staffing information posted were accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information.

Inspectors wroteBased on clinical record reviews, staff interviews and review of the facility policy, the facility failed to ensure there was adequate indication for the use of antipsychotic medication for one resident (#23). The deficient practice could result in resident receiving unnecessary psychotropic medication.