Harmony Health Center

Based on observation, interview and review, the facility failed to store dry foods in accordance with professional standards for food service safety, ensure cold food/dessert was at correct temperature for consumption and failed to ensure facility staff were wearing hair restraints in the kitchen. This has the potential to affect thirty-one (31) residents on thickened liquids, and 91 residents on regular diets out of one hundred and ninety-six (196) residents residing in the facility at the time of the survey. The findings include. On 8/4/25 at 8:22 AM during the initial kitchen observational tour with the Dietary Manager, two 46-ounce Ready Care Thickened Orange Juice Cartons were found to be expired, dated 03/2025 in the dry storage room.Interview on 8/4/25 at 8:30 AM the Dietary Manager revealed, two kitchen staff complete rotation of the items/foods in the dry storage room; every Monday; and stated: I will dispose of these items (two 46-ounce carton of thickened Orange Juice) in the garbage because of the items being outside of their expiration date. On 08/04/25 starting at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviewed and interviews, the facility failed to provide appropriate treatment to prevent worsening Urinary Tract Infections for one (Resident #2) out of two sampled residents, who had an indwelling urinary catheter; as evidenced by during hygiene care Resident #2's indwelling urinary catheter drainage collection bag and tubing were positioned on the bed below the level of the bladder with backflowing urine noted in the tubing. This deficient practice potentially increases the risk for worsening urinary tract infection and other severe complications. There were four residents with Urinary Tract Infections residing in the facility at the time of the survey. The findings included:Observation on 7/21/125 at 1:28 PM revealed Staff C, a Certified Nursing Assistant (CNA) performing hygiene care for Resident #2, Staff C, CNA positioned the urinary drainage collection bag and tubing between the resident's feet on the bed (photographic evidence) below the level of the bladder. The surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility failed to implement infection prevention and control practices in accordance with the facility's policy related to Enhanced Barrier Precautions (EBP) for one (Resident # 2) out of two sampled residents, as evidenced by staff failure to wear required Personal Protective Equipment (PPE) during indwelling catheter care. The findings included: Observation on 7/21/125 at 1:28 PM of Staff C, Certified Nursing Assistant performing hygiene care for Resident #2 who is under Enhanced Barrier Precautions (EBP)due to an indwelling urinary catheter. Staff C, Certified Nursing Assistant…performed hand hygiene donned gloves but did not put on a gown which is a required PPE for EBP and completed Resident #2’s hygiene care. The surveyor exited the room and informed the Director of Nursing (DON) of the identified concern. Record review of a demographic sheet revealed Resident #2 was admitted on [DATE] with diagnosis that included: Bacteriuria (presence of bacteria…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to accurately code the Minimum Data Set (MDS) Assessment for discharge for one (Resident #196) out of four residents reviewed for resident assessment. There were 192 residents residing at the facility at the time of the survey. The findings included: Record review of Resident #196's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] Section for Identification Information in subsection A 2105 for Discharge Status documented that the resident was discharged to a Short-Term General Hospital. Review of the Physician's Orders Sheet for March 2024 revealed Resident #196 had orders that included but not limited to: Resident transferred to home on [DATE]. Review of the nurses' progress notes for Resident #196 on 01/13/24 timestamped 09:00 documented: Resident was discharged home. Resident accompanied by family member. Resident is in stable condition and vital signs are within normal limits. Belongings were packed and given to the resident.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview facility failed to provide the necessary oxygen therapy according to physician's order for one resident (Resident # 453) out of nine residents sampled as evidenced by Resident # 453 receiving oxygen therapy at incorrect rate. The findings included: On 03/25/24 at 7:31 AM Resident #453 was observed in bed with oxygen in progress via nasal cannula at three Liters Per Minute (LPM). (photo evidence) On 03/27/24 at 7:28 AM Resident #453 was observed in bed with oxygen in progress via nasal cannula at a level between 2.5 and three LPM. (photo evidence) Record review of demographic sheet for Resident #453 revealed an admission date of 1/11/2024 and diagnosis that included sleep apnea and shortness of breath. Record review of Resident #453's Minimum Data Set (MDS) dated [DATE] Section C for cognitive status revealed a Brief Mental Status (BIMS) score of 6 on a scale of 0-15 indicating severe cognitive impairment. Section GG for functional status revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain an accurate record for one (Resident #95) out of seven residents reviewed for hospitalization. There was a total of 192 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's policy titled, Documentation in Medical Record Policy and Procedure (implemented April 2020, revised October 2023) documented: Policy Statement: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation; Policy Explanation and Compliance Guidelines: 1) Licensed staff and interdisciplinary team members shall document all assessments, observations and services provided in the resident's medical record in accordance with state law and facility policy and 4) Principles of documentation include, but are not limited to b)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure food safety by thawing frozen turkeys in an unsafe manner. There were 185 residents admitted to the facility at the time of the survey. The findings included: During the initial kitchen tour on 12/5/22 at 8:36AM with Staff B, the Dietary Manager. Four (4) large packs of frozen turkey were observed in the kitchen thawing in a sink at room temperature. This was observed in the pre wash area for pots. Staff B, acknowledged the turkey wasn't being thawed in the proper manner. After this observation, food service staff placed the turkey in pans and placed them in walk in refrigerator #2. The turkey was on the 12/5/22 dinner menu. Review of the facility's undated policy and procedure for Food: Preparation. The policy statement documents, All foods are prepared in accordance with the FDA (Food and Drug Administration) Food Code. Procedures: 2. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological and chemical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviewed and interviews, the facility failed to ensure narcotics/controlled substances were reconciled for 1 out of 5 medication carts (Unit 4 cart # 1) observed in the facility. There were 185 residents residing in the facility at the time of this survey. The findings included: On 12/06/2022 at 9:52 AM during the narcotic count and review of medication for cart 1 on unit 4 located on the second floor of the facility with Registered Nurse (RN) (Staff A) revealed, the narcotic count was inaccurate for Resident # 12's Alprazolam tablet 0.25 MG (milligram) and Resident # 82's, Lorazepam tablet 0.5 MG. Review of Resident #12's narcotic count sheet revealed, Alprazolam tablet 0.25 MG (1) tablet was last signed out as given at 7:48 AM on 12/05/2022 and the remaining tablets noted as 19, the medication bingo card had 18 tablets. On 12/06/2022 at 9:54 AM review of Resident #12's Electronic Medication Administration Record (EMAR) with Staff A revealed, Alprazolam tablet 0.25 MG (1) tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to demonstrate effective an plans of correction were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 812 Food Procurement, Store/Prepare/Serve-Sanitary as the facility failed to properly follow meat thawing procedures. This practice has the potential to increase the risk of negative resident outcomes and to affect all 185 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed, during a recertification survey with an exit date of 02/12/2021, Food Procurement, Store/Prepare/Serve Sanitary was cited related to the facility failed to store food at appropriate temperatures at or below 41 degrees Fahrenheit (F) in a walk-in cooler, failed to wash and sanitize dishes under sanitary conditions by operating a dish machine which did not reach the manufacturer recommended wash and rinse temperatures, failed to prepare and store food and clean dishes free from potential contamination,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.